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Motor Vehicle Accident Information
If you don’t know some of these options, just say you don’t know.
Step
1
of
2
50%
FOR MOTOR VEHICLE CASE ONLY:
PLAINTIFF/CLIENT(s):
Were you a driver, passenger or pedestrian?
Driver
Passenger
Pedestrian
OWNER:
Name
Address
Phone Number
OPERATOR:
Name
Address
Phone Number
MOTOR VEHICLE INFORMATION:
Type
Year
Model
State Registration
License Plate #
Insurance Information know as no-fault (name and address)
Name
Address
Claim No (only if accident was already reported)
DEFENDANT(s) - party liable in the subject accident:
OWNER:
Name
Address
Phone Number
OPERATOR:
Name
Address
Phone Number
MOTOR VEHICLE INFORMATION:
Type
Year
Model
State Registration
License Plate #
Insurance Information know as no-fault (name and address)
Name
Address
Claim No (only if accident was already reported)
{all_fields}
