We’ve created this form so you can easily keep track of all of your information in one convenient place. Just print this page and write your answers. If you would like an electronic copy, let us know by email or phone.

Information to Collect During or After an Injury Involving a Car Crash or a Slip and Fall

  • Name and address of ambulance service


  • Name and address of the emergency room


  • Names and addresses of all doctors and chiropractors


  • Dates admitted to all emergency rooms, hospitals, chiropractors or any other medical provider


  • Names of all people who were involved in the accident/incident


  • Names and addresses of witnesses to the accident/incident


  • Dates you missed work because of the accident/incident


  • Insurance company, insurance adjuster, and insurance claim number


  • Health insurance information


  • Medical payment coverage information (specific to auto insurance policies)


  • Employer information and dates of missed work

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