Statement - Paragon Subrogation Services, Inc.

Insured Statement Form

Your Information

* Indicates required field

Name of Driver *

First

Last

Phone Number *

Description of Vehicle:

Year: *

Make: *

Model *

Describe the Damage to your vehicle: *

Other Party's Information

Name of Driver *

First

Last

Phone Number *

Description of Vehicle:

Year *

Make *

Model *

Describe the Damage to other vehicle: *

Details of Accident (time, date, location):

Time *

Date *

City *

State *

Description of the accident including street names, direction of travel, traffic signals or controls, lane driven in, signals given, etc. : *

Whom do you feel to be at fault for this accident and why? *

Witness(es) (Please provide name, address and phone number): *

Please attach any evidence that you would like to provide here (photos, diagrams, written statements, police reports, and etc.):

Upload File *

Max file size: 20MB

Signature of Insured Driver:

Electronic Signature: *

Date: (MM/DD/YYYY) *

Submit