MVA Accident Plan Other Drivers: Name________________________________________________ Address ____________________________________________ Telephone Number ___________________________________ License Number _____________________________________ Insurance Company __________________________________ Year, Make, Model, Color of Vehicle_________________ Other Owners (if not the driver): Name________________________________________________ Address ____________________________________________ Telephone Number ___________________________________ License Number _____________________________________ Insurance Company __________________________________ Witnesses: Name________________________________________________ Address ____________________________________________ Telephone Number ___________________________________ Name________________________________________________ Address ____________________________________________ Telephone Number ___________________________________ Passengers: Name________________________________________________ Address ____________________________________________ Telephone Number ___________________________________ Name________________________________________________ Address ____________________________________________ Telephone Number ___________________________________ Police Officer: Name________________________________________________ Badge and Department Number_________________________ Notes: ____________________________________________________ ____________________________________________________ Langlitz Chiropractic Health & Rehabilitation Group, PC. (413) 732-4800 / 732-7240 1) Stop your car and Turn off your engine to minimize the risk of fire. 2) Get out of your vehicle. Remain on the accident scene and remove yourself from further danger by getting out of your vehicle and out of traffic. If possible, collect information about the accident at the scene, or as soon after as is practical. 3) Call 911 for police or medical assistance. Even if there are no injuries, assistance may be necessary to clear the accident scene, handle traffic, and file an accident report. Tell the police if any party is injured or has left the scene of the accident. If the police fail to arrive at the scene, go to the local police department to file the appropriate information. If the other vehicle left the scene of the accident, it is very important to give the police whatever information you were able to obtain (license plate number, description of vehicle and driver). 4) Exchange Information no matter who is at fault. Exchange names, addresses and insurance information, and help the injured at the scene of an accident. Include time and place of accident; weather and road conditions, and other circumstances of the accident; of those involved, including other drivers, passengers, witnesses, etc.; driver's license number, insurance company and policy number of other drivers; vehicle make and model, and license plate number of other involved vehicles; name, department and badge numbers of responding police officers and a copy of the police report. If it is safe to do so, move vehicles off busy roads and set up flares. 5) Don't sign anything except a ticket, citation or report issued by police. Never sign anything else at the accident scene. Signing some documents jeopardizes your rights. 6) Obtain medical attention as soon as possible. Shock and trauma can mask serious injuries. Following first-aid treatment you may receive at the scene, follow up with your doctor of chiropractic for a complete examination, even if you "feel" fine. Moreover, EMS and ER technicians do not diagnose the vertebral subluxation complex, nor recognize soft tissue injuries as life threatening. Remember that accidents with little or no damage can be more hazardous than accidents with damage! 7) Call your insurance company and give them all the information you have collected. If you were injured or if your car was damaged, your insurance company needs to be notified "promptly" in order to conduct their investigation into the claim and coverage. Your claim may be denied by the insurance company if there is no or late notice. For this reason, it is wise to follow up with a written notice. 8) Don't discuss the accident. Except for giving necessary details to police, medical personnel, your insurance company, or your attorney. 9) File a report with the police within 5 days after the accident if there are personal injuries or property damage exceeded a minimum amount. Failure to file an accident report may result in loss of your driver's license and a fine. You can obtain an accident report from the police department, our office, or an attorney. 10) Call Langlitz Chiropractic Group, PC. (413) 732-4800