Contact info with health insurance

ICBC claims number

Name - first and last:

Address

Phone number (evening)

Phone number (daytime)

Phone number (cell)

Email address (please check carefully)

Date of accident

In the accident you were:

Driver
Passenger

Accident location / address

Describe injuries

List of hospitals / doctors seen so far

Any previous injuries. If so, please describe and provide dates

Any chronic health problems other the injuries from the accident. If so, please describe

List current medication and dosage

List current treatment plans