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Motor Vehicle Accident Information .pdf


Original filename: Motor Vehicle Accident Information.pdf
Title: Motor Vehicle Accident Information
Author: Scott Conklin

This PDF 1.5 document has been generated by Microsoft® Office Word 2007, and has been sent on pdf-archive.com on 21/02/2018 at 00:28, from IP address 71.193.x.x. The current document download page has been viewed 106 times.
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Motor Vehicle Accident Information
Today’s Date________________________

Date Of Accident_________________________

Name _________________________________________________________________________
Do you have an attorney?
Yes
No
If yes, who?
Name_____________________________________________
Address____________________________________________
____________________________________________
Phone# ____________________________________________
Patient’s Auto Insurance Company: Patient was driver or passenger in own vehicle.
(please give PIP info and not the Agent’s info)

Company Name _________________________________ Phone #_________________________
Policy Holder’s Name ______________________________Policy #________________________
Insured’s Auto Insurance Company: Patient is passenger of vehicle not their own.
(please give PIP info and not the Agent’s info)

Company Name__________________________________ Phone # ________________________
Policy Holder’s Name______________________________ Policy # ________________________
Other Driver’s Auto Insurance Company: Other vehicle involved in incident- possibly at fault (third party).
(please give PIP info and not the Agent’s info)

Company Name _________________________________ Phone # ________________________
Policy Holder’s Name _____________________________ Policy # ________________________
Payment is due at the time of service unless other arrangements have been made. Patients involved
in litigation (law suits) or require third party payment is ultimately responsible for payment of all
services.
MY SIGNATURE IS AN ACKNOWLEGDEMET THAT I HAVE READ THE ABOVE AND AGREE TO ABIDE
BY THE SAME.

Patient Signature __________________________________________ Date _________________
Guardian Signature ________________________________________ Date _________________

****************************************************************************************************************
* Office use only:
Primary Claim # ________________________
3rd Party Claim # ______________________
Adjuster Name _________________________
Adjuster Name ________________________
Phone # ______________________________
Phone # _____________________________
Bill to: _______________________________
_______________________________
_______________________________

Bill to: ______________________________
______________________________
______________________________

Date Verified _________________ By ___________


Document preview Motor Vehicle Accident Information.pdf - page 1/1

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