Name

Email Address

Phone Number

When and where did the accident occur?

What were the conditions? Light/Dark? Wet/Dry? Snow/Ice?

Were you the driver or a passenger on the motorcycle?

Who owns the motorcycle?

Is it insured?
Yes
No

Were you wearing a helmet when the accident occurred?
Yes
No

Was another vehicle involved in the accident?
Yes
No

If not, could you tell why the accident happened?
Yes
No

Did you notice any wobbling or other problem with control or maneuverability of the motorcycle just before the accident occurred?
Yes
No

Who is the manufacturer of the motorcycle?

What model is it?

Did the police come to the scene of the accident?
Yes
No

Were any citations issued or arrests made?
Yes
No

In your opinion, was alcohol a factor in causing the accident?
Yes
No

Do you have a copy of the police report?
Yes
No

Were you injured in the accident?
Yes
No

Were you taken to the hospital?
Yes
No

If so, how were you taken there?

What medical treatment have you received? Are you currently receiving medical treatment?

Were you insured on the day of the accident?
Yes
No

Was the driver of the other vehicle(s) insured?
Yes
No

Are you currently under a physician's care for the injuries sustained in the accident?
Yes
No