Multiple Order Information:    

     * required fields

Claim Number:    *   Loss Date: * Insured:*

Your Name:        *   Your Phone:   

Your  e-mail:                Company:       

 Mailing Address   

Scroll and complete as many services as you need:

(leave blank the services you do not need)

Scene Investigation Request:

FAX police report to:  512-535-2347  (write claim number at top of report)  

Digital:       35mm:     Both:      Video:

City where accident occurred

Street Address or Intersection

Light sequence needed?       

Witness Canvass?:                                

Special Instructions: 

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Vehicle Photos Request:

Digital:       35mm:     Both: 

Vehicle Owner:                  

Owner Phone:                      

Vehicle Location:               

Vehicle Year/make/model:

Vehicle Color:                     

License Plate:                     

Area of Impact:                    

Special Instructions:       

for multiple vehicles, you may add additional information in Special Instructions area.

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Medical Records Request:

Please fax signed medical authorization to: 512-276-6768

Records:     Itemized Bills:    Both:    (If billing is at a separate location, additional retrieval fee may apply)

Injured Party:    DOB: SS#:

Medical Provider:   Provider Phone:  

Physician:                        Treatment Dates:

Medical Provider:   Provider Phone:  

Physician:                        Treatment Dates:  

Medical Provider:   Provider Phone:  

Physician:                        Treatment Dates:  

Special instructions (add additional injured parties and providers): 

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Recorded Statement Request:

Please fax police report to : 512-535-2347

Obtain Statement from (name):

Day Phone:    Evening Phone: Cell:

Context Information (who is this person and how were they involved?):

Important Questions:

Special Instructions: 

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Police Report Request  

(Reports are picked up from Austin P.D. and nearby city stations on Tues. and Thurs.)  

****** REQUIRED:  Case #   - or  -     DOB and Driver's License of a driver ****** 

Department:   Case #: 

Accident Location: 

Driver #1          DOB: TDL:

Driver #2          DOB: TDL:

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Face to Face Meeting:

Please fax police report and medical authorization to : 512-535-2347

Injured Party: Parent (if minor):

Contact Phone Number:

Will include signed authorization, profile of claimant and injury and explanation of expectations*

Special instructions (photos, explanations other than noted below, etc.): 

*  Will explain that company adjuster will discuss settlement with them when they are ready.

 Settlements normally include consideration of reasonable and necessary medical charges,

 reasonable wage loss and a general damages amount for pain, suffering, inconvenience etc.

 In some circumstances adjuster may be able to project some medical charges and wages to be

 incurred.

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Mediation Attendance:

Injured Party (plaintiff):       Plaintiff Attorney:        

Plaintiff Attorney Phone:

Defense Attorney:             Defense Atty. Phone:

Mediation Location:      

Mediation Date and Time:

Instructions/Details (or you may fax to 512-260-9179 or call 512-260-2700)

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Arbitration Preparation Request:

Send all supporting paperwork, evidence and forms to the following address:

Weatherly Claim Services,   P.O. Box 429, Cedar Park, TX 78630

Enter your overnight package tracking information here:

Make sure you also complete the customer information section at the top of the form.

Special Instructions:

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After Hours Contact Request:  

Person to contact:

Home Phone:   Work Phone: Cell:

Important Questions: 

Special Instructions or Additional Persons to contact :

(include additional claim numbers, phone numbers and questions)

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Notification/Door-Knocker:

Person you want to notify:

Address:                            

Phone1:       Phone2: Phone3:

Special Instructions:

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Special Requests:

Tell us what you need :

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