Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by filling in the insurance company information, including your claim number, policyholder name, date of loss, policy number, and the name of your claim representative.
3. Next, input the injured person's information: their full name, date of birth, gender, street address, social security number (required), and contact phone numbers.
4. Provide details about the accident, including the accident's date, time, and a brief description.
5. Indicate whether the injured person was a driver, passenger, or pedestrian, and provide details about any vehicles involved.
6. Answer questions regarding medical treatment for injuries sustained from the accident, including the name of the treating doctor and any treatment received at a hospital.
7. Complete the employment information section, detailing if the injury affected wages or salary, and whether any claims have been filed under Workers' Compensation.
8. Lastly, review the authorizations for medical and wage information, sign and date the form, confirming that all information provided is accurate.
9. Once completed, ensure to save your changes. You can then download, print, or share the completed form as needed.

Start filling out your form online today to secure your benefits.