Welcome to the Law Offices of
Mallery and Stern, APC
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Accident Information
Print
this form and keep a copy in your
Glove Box
• Call the police if persons are hurt or property damage is in
excess of $500.00
• Call your insurance company iediately to report the
accident
• Call your doctor if you are hurt or in
pain
• Call the Law Offices of MALLERY & STERN (310) 473-0777 or
(800) 564-5565 or JAFFEE, MALLERY & STERN (909) 948-9999 for
advice
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| Date: | |
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| My Name is: | |
| My Address: | |
| My Phone Number is: | |
| My email address is: | |
| Police Report: | |
| My Insurance Carrier is: | |
| My Insurance Carrier Tel. #: | |
| My Policy #: | |
| Witness Name: | |
| Witness Address: | |
| Witness Telephone#: | |
| Other Party: | |
| Other Party Address: | |
| Other Party Telephone #: | |
| Other Party Insurance Carrier: | |
| Other Party Policy Number: | |
| Agent's Telephone #: | |
| Accident Description:
Describe what happened (Include street names, time of day, etc.) |
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