Contributory Negligence Report
If you were recently involved in a car accident in the state of Georgia and believe the negligence assigned to you by an auto insurance carrier to be inaccurate, please fill out this form. Data collected will be provided to the Georgia Department of Insurance.
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Name of Individual Filing Report: *
Date of Incident: *
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Location of Incident: *
City & State
Name of your insurance agency: *
Name of your insurance agent:
Name of your automobile insurance carrier:
 *
Claim number assigned by your carrier:
Was the vehicle involved in the accident a personal or commercial vehicle? *
Was a Police Report Filed?
 *
If so, which party was assessed fault in the police report?
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