Information Needed for Auto Claims Name: Email Address Accident Report How much damage was done to your vehicle? Liability Information (at fault insurance info) Company Name & Address Medical Claim Number Phone Number Adjuster Name Fax Number Med Pay (your auto insurance info) Company Name & Address Medical Claim Number Phone Number Adjuster Name Fax Number Dollar Amount Other Medial Provider's Info Attorney Information (if applicable) - Letter of Representaion If you are human, leave this field blank.
