ProMedical, LLC
PO Box 310, Bedford, MA 01730-0310
(800) 722-1555 Fax (800) 767-7556

Patient Automobile Accident Form

(1sPIP) This is not a secure form - your responses will be e-mailed to us.

Section 1 - Your Information

Our file# (ournum) (required)
Your full name (realname): (required)
Your e-mail address (email): (required)
Name of medical provider where you were treated for this accident:

Were you the driver of the automobile? YES NO

Section 2 - Auto Insurance Information

Was your insurance company notified of this accident? YES NO
Vehicle Owner's Name: (Check if you own the vehicle )

Vehicle Owner's Auto Insurance Company Name:

Auto Insurance Company Address:

Auto Insurance Policy #
Insurance Claim #
Was there more than one vehicle involved in the accident? YES NO
If "YES", Name(s) of the other Driver(s):

Insurance Company(s) of other driver(s):

Section 3 - If an attorney is handling your case

Name of your Attorney:

Mailing address of your Attorney:

Telephone number of your Attorney:

Press this to , or, press to clear this form .

Thank you!

Auto Accident Claim

Other Forms:

Employee - Work Related

Employer

ProMedical, LLC PO Box 310, Bedford, MA 01730-0310 (800) 722-1555 Fax (800) 767-7556

Section 1 - Your Information

Section 2 - Auto Insurance Information

Section 3 - If an attorney is handling your case

ProMedical, LLC
PO Box 310, Bedford, MA 01730-0310
(800) 722-1555 Fax (800) 767-7556