Auto Accident Form Below is a comprehensive form which will help you provide us with information required to evaluate your claim. By sending us this information, you will essentially be helping us create your initial file. When we contact you we will have a good deal of information on hand with which to help you. If you are unsure of any of the required information, please contact us directly by email at attorneys@sokoloffandweinstein.com or by phone at 561-790-6788 or 561-790-4505. Click here to request a copy or download our Helpful Hints for Auto Accidents form to keep in your vehicles.
*First Name: *Last Name: Address: *City: *State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY *Zip Code: *Contact Phone: Other Phone: When is the best time for us to contact you?: Morning Afternoon Night Any Time Email: *Date of Accident: Time of Accident: *Location of Accident - City: *Location of Accident - State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY *Was a Police Report Filed?: Yes No If so, when (date)?: If a report was filed, in what state?: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY *Where you the Driver, Passenger, or Pedestrian?: Driver Passenger Pedestrian If you were not the Driver, who was?: *Who's Vehicle was involved in the accident?: My OWN vehicle Vehicle of a RELATIVE Vehicle of a FRIEND PUBLIC Transportation OTHER *How many people were in your vehicle?: 1 2 3 4 5 6 or more How Many Vehicles were involved in the Accident?: 1 2 3 or more *Briefly Describe Your Accident: *Are you currently Seeing a Doctor because of this accident?: Yes No If so, what is the Doctor's Name?: Doctor's City: Doctor's State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Doctor's Phone (if known): *Do you have Health Insurance?: No Yes If so, who is your Health Insurer?: Health Insurer State (if known): AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Health Insurer Phone Number (if known):