MOTOR VEHICLE ACCIDENTS CONTACT FORM

 
Name:
Street:
City:
State/Province:
Zip/Postal Code:
-
Email:
Phone:
When and where did the accident occur?:
What were the conditions? Light/Dark? Wet/Dry? Snow/Ice?:
Where were you in the vehicle? Were you driving?:
Who owns the vehicle?:
Is the vehicle insured?:
 
Please describe how the accident happened.:
Did the police come to the scene of the accident?:
 
If so, do you have a copy of the police report?:
 
Were any citations issued or arrests made?:
Do you believe that alcohol was a factor in causing the accident?:
Were you injured in the accident?:
 
Were you taken to the hospital?:
What medical treatment have you received?:
Are you currently receiving medical treatment?:
 
Was the other driver injured?:
 
Were any passengers injured?:
 
Please list any other concerns.:

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EAST OFFICE
4520 South Pecos
Road, Suite 4
Las Vegas, NV 89121
Phone: 702-451-3900
Fax: 702-451-1448
Map and Directions

WEST OFFICE
2830 S Jones Blvd.
Suite 3
Las Vegas, NV 89146
Phone: 702-451-3900
Fax: 702-451-1448
Map and Directions