VEHICLE INCIDENT QUESTIONNAIRE

Name:*

Email:

Phone No:

Address:

City:

State:

Zip:

Insurance Company:

Claim No. :

Speed your vehicle was traveling at the time of incident?

Speed other vehicle/object was traveling?

Did your vehicle slide or skid?

Dash lights on?

Does your vehicle pull to one side or does it drive straight?

Were there any child safety seats in use during the time of the incident?

Did your body physically impact any components of the vehicle? For example, dash, console or door panels?

Any loose items in the trunk/pickup box or cabin of the vehicle?

Additional Info: