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1.  List the date of your accident.  / /  

2.  Indicate if you were a driver or passenger.
 Driver  Passenger 

3.  Whose car were you in?
Own CarSelect OneAnother individual's carA vehicle owned by a businessRental carOther  

4.  Do you own an automobile?  Yes  No

5.  Do you carry automobile insurance?  Yes  No

6.  On your automobile insurance policy on any vehicles you own, indicate whether you have elected the full tort option or limited tort option.
 Full tort (This allows you your full right to sue for all damages)
 Limited tort (This restricts your right to sue for full damages)
 Unsure

7.  Please indicate where the accident occurred.
 outside of Pennsylvania  in Pennsylvania
If accident occured in Pennsylvania, what county?
Select a countyAdamsAlleghenyArmstrongBeaverBedfordBerksBlairBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthhamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYork 

8.  Have you missed work as a result of your injuries?
 Yes  No
If yes, how long have you been out of work?
 number of  Days  Weeks  Years

9.  Did you sustain injuries in the automobile accident?
 Yes  No

10.  Describe your injuries.
 

11.  Briefly describe how the accident occurred.