2494 Whitney Avenue · PO Box 5616 · Hamden, CT 06518 | Phone: (203) 281-7376 · Fax: (203) 281-7020

 203.281.7376

Practicing Over 30 Years
In Your Local Community

Monday - Friday
9:00 a.m. to 5:00 p.m.
Saturdays
By Appointment Only

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Fact Sheet

Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

  1. DO NOT TALK TO THE OTHER PERSON'S INSURANCE ADJUSTER UNTIL YOU CAN MEET WITH US.
  2. MOST APPOINTMENTS CAN BE SAME DAY.
PERSONAL INJURY FACT SHEET
First Name
M.I.
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Country
Phone
Date of Birth
Employer
Occupation
Bold = Required field
ACCIDENT INFORMATION
Date of Accident
Location (Be Specific)
How Did Accident Happen?
Witnesses
Car You Were In (Make / Model / Year)
Color
Auto Insurance
Policyholder
Policy Number
DEFENDANT DRIVER / OWNER
Vehicle Make / Model / Year
Color
Insurance
Policy Number
Adjuster (If You Know)
Claim Number
Injuries
Hospital?
Yes
No
Ambulance?
Yes
No
Name
Are You Under The Care Of A Physician Now?
Yes
No
Name
Address
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