HF Auto Accident Info 091713

auto accident basic information about the accident date accident occurred or started / / time of day when accident occurred or started am / pm describe how the accident took place describe the condition or symptoms caused by the accident auto accident specific information were you the □driver □passenger □pedestrian automobile you were in year make model damage to your car □front□rear□pedestrian□driver side□passenger side□bumper□fender damage amount estimate $ □minor□major□totaled other automobile year make model damage to other car □front □rear □pedestrian □driver side □passenger side □bumper □fender damage amount estimate $ □minor□major□totaled where did the accident happen? street names city/state was it a? □controlled intersection□uncontrolled□not intersection was there a traffic light? □none□green□red□turn arrow□stop sign were you moving □slowly □normal posted speed □stopped weather conditions □sunny□rainy□cloudy street surface □dry□wet□slick □icy□pavement□other type of impact □rear end□front□side impact□roll over brakes on impact □locked tight□loosely applied□foot not on brake how far did your car move?□did not move □moved 1 5 ft □moved 6 10 ft □moved over 10 ft where were you seated in the vehicle wearing seat belt? □ yes □ no shoulder harness □ yes □ no headrest □ yes □ no headrest position □up□ down is the car equipped with airbags?□ yes □no did they deploy?□ yes □ no did you see the impact coming?□ yes □ no did you brace yourself for impact? □ yes □ no on impact, your head was looking □ahead□behind□up□down□to the right□to the left on impact were you □thrown forward□thrown backwards□thrown sideways □other did your body hit anything inside the car? □ yes □ no body part what did it hit? head trauma?□ yes □ no loss of consciousness?□ yes □ no for how long? do you remember the accident happening? □ yes □ no hospital?□ yes □ no name of hospital how long there? taken by ambulance? □ yes □ no□other x rays taken?□ yes □ no x ray areas □neck□mid back□low back□ other x rays medication given?□ yes □ no rx other instruction follow up are you represented by an attorney? □yes □no attorney name/firm phone # financial your auto insurance carrier your major medical carrier insurance name adjuster policy/claim # med pay available other financial other drivers insurance carrier insurance name adjuster policy/claim # fax