A Salem, Oregon Law Firm Specializing in Death & Serious Injury; Property Damage; Underinsured Motorist Claims; Pedestrian Accidents; Hit & Run; Insurance Headaches; Loss of Wages and more. Experienced attorneys and support staff who will assist & guide you through your difficult times.

 

 

 
PERSONAL INJURY INCIDENT
William W. Morgan & Associates

Please take the time to fill this form out as completely as possible.
Fields marked with an * are required
 Who's Hurt?
Name:   *
Address: 
Phone Number(s): 
Email:   *
Not a motor vechicle accident?  Go to "How did it happen?"
 Injured's Auto Insurance
Who was driving:     Policy Holder: 
Address of driver: 
(if not the injured)   		   Injured on the job?:    
Insurance Company:     Policy #: 
Claim #:     Adjuster:     Phone: 
Vehicle:  Year    Make    Model     Lic #:     Damage/Totaled: $
 Bad Driver Info
Driver's Name:     Policy Holder: 
Address:     On the job?:    
Phone:     Driver's License #: 
Insurance Company:     Policy #: 
Claim #:     Adjuster:     Phone: 
Vehicle:  Year    Make    Model     Lic #:     Photos?: 
More Vehicles  
Involved?: 
Did bad driver   
say anything?: 
 How did it happen?
Date:     Time:    Location: 
Weather/Road/  
Traffic/Site conditions: 
Description  
of incident: 
 *
 Did the police come?:     Agency(s): 
 Did you file DMV report?:     Do you need a rental car?: 
 Have you been offered a settlement?:     If Yes, Amount:     Date of offer: 

 

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