Auto Accident Intake

First Name

Claims Adjuster Name

Last Name

Other Parties Insurance?

Your Insurance:

Date of Accident

Claim Number:

Claims Adjuster Phone Number

Attorney Name:

Attorney Phone Number:

Your vehicle estimated speed?

The other vehicle estimated speed?

Name of emergency room?

I confirm that the information given in this form is true

serving: Millerburg, Wooster, Loudonville, Berlin, Sugarcreek, Coshocton