Accident Checklist

Accident Checklist / Case Submission

Date of accident *

Time of accident *

Location of accident *

Weather conditions *

Did the police investigate the accident? *

Police case number / report number *

Victim Info

Name *

First

Last

Involvement *

Phone Number *

Email *

Injured *

Accused Info

Name *

First

Last

Involvement *

Phone Number *

Email *

Injured *

List any passengers *

Victim Vehicle

Make *

Model *

Year *

Registration (i.e. CT- ABC123) *

Insurance company name and policy number *

Describe vehicle damage *

Damage rating *

List any passengers *

Accused Vehicle

Make *

Model *

Year *

Registration (i.e. CT- ABC123) *

Insurance company name and policy number *

Describe vehicle damage *

Damage rating *

Supporting Documents and Info

Please describe how the accident occurred *

Witness information *

Upload file or photo *

Max file size: 20MB

Upload file or photo *

Max file size: 20MB

Upload file or photo *

Max file size: 20MB

Upload file or photo *

Max file size: 20MB

Please note all inquires and submissions are sent to a general mailbox and not a specific attorney. To reach a specific attorney please use the email provided in their profile. If you are in need of immediate assistance please call our office or contact your attorney directly. Submission of this form does not create an attorney-client privilege between you and Sullivan, Attanasio, Miller & Lubonja, nor is it intended to do so. Likewise, be advised that sending an email to us via Internet email will not create an attorney-client relationship. If you are not currently a client of Sullivan, Attanasio and Miller, any information sent to us by Internet email or through the website will not be privileged.

Submit