Motorcycle Accidents Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

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 

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