Motor Vehicle Accident Information Form

First Name

Last Name

Phone *

Email *

When did your accident occur? *

How did the accident happen?

Is your PIP open? (Personal Injury Protection insurance is requred for all drivers in Oregon.) *

Yes

Are you currently working with a PI Lawyer? *

Yes

Did this incident happen during work or using a work vehicle?

Yes

Did you fill out a DMV traffic report?

Yes

Who is your car insurance provider?

Who is the other vehicle's car insurance provider?

What is your claim number?

What is the other vehicle's claim number?

Who is your adjuster?

Eligibility: By signing up this form, you warrant that you are 18 years of age or older and have the legal authority to enter into these terms. I agree to the terms & conditions provided by the company. By providing my phone number and email, I agree to receive text messages from the business. I, the undersigned, waive and release and agree to hold harmless and indemnify the Prolific Wellness, its employees, agents, officers and directors against any and all claims any way connected with my participation. This agreement is binding on my heirs, executors, administrators and assigns.