Motor Vehicle Injury Report Template

Motor Vehicle Injury Report Template

[Organization / Employer / Law Firm / Personal Records]
[Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Email: [Email Address]

1. Injured Person / Claimant Information

Full Name: [First, Middle, Last]
Date of Birth: [MM/DD/YYYY]
Age: [Age]
Gender: [Gender]

Home Address:
[Street Address]
[City, State/Province, ZIP/Postal Code]

Phone Number: [Primary Phone]
Email Address: [Email Address]

Role in Incident (check or describe):

• Driver of Vehicle 1

• Passenger in Vehicle 1

• Driver of Vehicle 2

• Passenger in Vehicle 2

• Pedestrian

• Cyclist / Motorcyclist

• Other: [Describe]

Employer (if relevant): [Employer Name]
Job Title: [Job Title]

2. Incident and Location Details

Type of Incident (check all that apply):

• Car vs. Car

• Car vs. Truck / Commercial Vehicle

• Car vs. Motorcycle

• Car vs. Pedestrian

• Multi-vehicle crash

• Single-vehicle crash

• Other: [Describe]

Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]

Exact Location (street, intersection, highway, mile marker, city, state/province):
[Location description]

Road Type: [Highway / City Street / Rural Road / Parking Lot / Other]
Traffic Controls Present (check all that apply):

• Traffic light

• Stop sign

• Yield sign

• Roundabout

• None

• Other: [Describe]

Weather at Time of Crash: [Clear / Rain / Snow / Fog / Other]
Lighting Conditions: [Daylight / Dawn / Dusk / Dark – Streetlights / Dark – No Streetlights]
Road Surface: [Dry / Wet / Icy / Snow / Gravel / Other]

3. Vehicle and Driver Information

Vehicle 1 (Your Vehicle, if applicable)

Driver Name: [Name]
Driver’s License Number and State/Province: [Number, State/Province]

Vehicle Owner (if different): [Owner Name]
Year, Make, Model: [Year, Make, Model]
Color: [Color]
License Plate and State/Province: [Plate, State/Province]

Insurance Company: [Company Name]
Policy Number: [Policy Number]
Insurance Phone: [Phone Number]

Vehicle 2

Driver Name: [Name]
Driver’s License Number and State/Province: [Number, State/Province]

Vehicle Owner (if different): [Owner Name]
Year, Make, Model: [Year, Make, Model]
Color: [Color]
License Plate and State/Province: [Plate, State/Province]

Insurance Company: [Company Name]
Policy Number: [Policy Number]
Insurance Phone: [Phone Number]

[If more than two vehicles were involved, copy and expand this section for Vehicle 3, Vehicle 4, etc.]

4. Description of Crash (Accident Narrative)

Provide a clear, factual description of how the crash occurred. Avoid opinions or blame; focus on events.

Before the collision, my vehicle was traveling [direction, lane, approximate speed if known] on [road name]. The other vehicle(s) was/were traveling [direction, lane, approximate speed] on [road name].

Describe step by step:

1. Actions taken by you (stopping, turning, changing lanes, proceeding through intersection, etc.):
   [Narrative]

2. Actions taken by the other driver(s), as you observed:
   [Narrative]

3. Point of impact (front, rear, side, multiple impacts) and how the vehicles moved afterwards:
   [Narrative]

4. Any skid marks, evasive actions (braking, swerving), or horn use:
   [Narrative]

If you were a pedestrian or cyclist, describe where you were located (crosswalk, sidewalk, shoulder, lane) and how the vehicle approached.

If your view was blocked or you did not see the entire incident, describe what parts you did and did not see.

5. Injury Details

Body Part(s) Injured (check or describe):

• Head / Scalp

• Face / Eye / Nose / Mouth / Jaw

• Neck / Cervical spine

• Shoulder / Arm / Elbow / Wrist / Hand

• Chest / Ribs

• Upper / Mid / Lower Back

• Abdomen / Hips / Pelvis

• Thigh / Knee / Lower Leg / Ankle / Foot

• Multiple areas

• Other: [Describe]

Side of Body: [Left / Right / Both / Center / Unknown]

Type of Injuries (check all that apply):

• Bruise / Contusion

• Cut / Laceration

• Abrasion / “Road rash”

• Sprain / Strain / Whiplash

• Suspected fracture / fracture

• Concussion / head injury (suspected)

• Soft tissue injury (muscles, ligaments, tendons)

• Internal injury (suspected)

• Other: [Describe]

Symptoms Noticed Immediately After Crash:
[Example: pain, dizziness, headache, nausea, numbness, weakness, confusion, shortness of breath.]

Current Symptoms (in your own words):
[Free-text description of your pain, limitations, headaches, sleep problems, emotional effects, etc.]

Pain Level Today (0–10; 0 = no pain, 10 = worst pain imaginable):
Pain Score: [0–10]

6. Medical Treatment

Did you receive treatment at the scene?

• Yes – describe (first aid, EMS assessment): [Description]

• No

Was an ambulance called?

• Yes – Transported to: [Hospital/Facility Name]

• No

Initial Medical Care (check all that apply):

• Emergency room visit – Facility: [Name] – Date: [MM/DD/YYYY]

• Urgent care visit – Facility: [Name] – Date: [MM/DD/YYYY]

• Primary care doctor – Provider: [Name] – Date: [MM/DD/YYYY]

• Specialist (orthopedic, neurologist, etc.) – Provider: [Name] – Date: [MM/DD/YYYY]

• No medical care yet

Ongoing Treatment Providers (list all relevant):

Provider 1:
Name: [Name] – Specialty: [Specialty] – Facility: [Name]
City/State: [City, State]
First Visit: [Date] – Most Recent Visit: [Date]

Provider 2:
Name: [Name] – Specialty: [Specialty] – Facility: [Name]
City/State: [City, State]
First Visit: [Date] – Most Recent Visit: [Date]

Treatments Received (check all that apply):

• Physical examination and advice

• X-rays

• MRI / CT scan / other imaging

• Prescription medications

• Over-the-counter medications

• Physical therapy / rehabilitation

• Chiropractic treatment

• Injections (pain management, steroids, etc.)

• Surgery or invasive procedure

• Counseling or psychological support

• Other: [Describe]

Have you been given written work, activity, or driving restrictions?

• Yes – describe: [e.g., “No lifting over 10 lbs,” “No driving,” “No sports.”]

• No

• Not sure

7. Work, Driving, and Daily-Life Impact

Employment Status at Time of Crash: [Employed full-time / part-time / self-employed / unemployed / student / other]

Employer Name: [Name]
Job Title: [Title]
Normal Work Schedule (before crash): [Example: “Mon–Fri, 9:00–17:30”]

Have you missed work because of this motor vehicle injury?

• Yes

• No

If Yes, specify:

• Dates absent: From [MM/DD/YYYY] to [MM/DD/YYYY or “Ongoing”]

• Approximate full days missed: [Number]

• Approximate partial days (left early/arrived late): [Number]

Briefly describe how your injuries affect your work duties:
[Free-text, e.g., lifting, standing, driving, computer work, concentration.]

Driving / Transportation Impact:

• Unable to drive temporarily

• Restricted from driving by doctor or law (e.g., license suspension, DUI-related order)

• Relying on others or public transit

• No change

Daily Activities Affected (check all that apply and briefly describe):

• Personal care (bathing, dressing, grooming) – [Description]

• Household tasks (cleaning, cooking, shopping) – [Description]

• Caring for children or family – [Description]

• Hobbies, sports, exercise – [Description]

• Sleep or mood – [Description]

8. Property Damage Summary (If Applicable)

Vehicle You Were In (Year, Make, Model): [Vehicle]

Describe damage to your vehicle (areas impacted, severity):
[Free-text, e.g., “Front bumper and hood crumpled, driver-side headlight broken.”]

Is your vehicle drivable?

• Yes

• No

Was your vehicle towed?

• Yes – Towed by [Company] to [Location]

• No

Other Property Damaged (phone, glasses, equipment, etc.):
[Free-text list]

9. Witnesses and Police / Administrative Reports

Did police respond to the scene?

• Yes – Agency: [Police/Sheriff/Highway Patrol]

  • Officer Name(s): [Name(s)]

  • Report / Case Number (if known): [Number]

• No

• Unknown

Was any citation or ticket issued (to you or another driver, if known)?
[Brief description or “Unknown”.]

Witness 1:
Name: [Name]
Phone / Email: [Contact]
Short Description of What They Saw: [Summary]

Witness 2:
Name: [Name]
Phone / Email: [Contact]

[Add additional witness lines as needed.]

10. Insurance and Claim Information

Your Auto Insurance Company: [Name]
Policy Number: [Number]
Claim Number (if opened): [Number]
Adjuster Name and Contact (if known): [Name, Phone, Email]

Other Driver’s Insurance Company (if known): [Name]
Policy or Claim Number (if known): [Number]

Other Coverage (check all that apply):

• Health insurance

• MedPay / Personal Injury Protection (PIP)

• Workers’ compensation (if on-the-job)

• Disability insurance

• Other: [Describe]

11. Attachments Checklist

Check all documents attached or available on request:

• Police or accident report

• Photographs of scene and vehicles

• Photographs of injuries

• Medical records or visit summaries

• Medical bills and Explanation of Benefits (EOBs)

• Work status notes or disability slips

• Employer letter confirming time missed

• Repair estimates or total-loss documents

• Other: [Describe]

12. Declaration and Signature

I, [Full Name], declare that the information provided in this Motor Vehicle Injury Report is true and accurate to the best of my knowledge and recollection. I understand that this report may be used by insurers, employers, medical providers, or legal representatives in connection with my claim or case.

I understand that this form does not itself determine legal fault, coverage, or benefits, and it is not a substitute for legal, medical, or insurance advice.

Signature: _______________________________
Printed Name: [Your Full Name]
Date Signed: [MM/DD/YYYY]

Place Signed (City, State/Province): [Location]