MVA Form First Name*Last Name*Email* Phone*When was your accident?* MM slash DD slash YYYY Severity of Injury*(Please select)DeathCatastrophicSubstantial InjurySoft TissueNo Injury InvolvedWas the at-fault party any of the following:(Please select)City VehicleCommercialCompany VehicleNon-CommercialRideshare (Uber/Lyft)SemiTaxiUnknownHow did your accident happen?*Were you insured at the time of the accident?*(Please select)YesNoUnknownWhat is Your Address? Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Languague Preference*(Please select)EnglishSpanishChineseKoreanTagalogVietnameseArmenianFarsiArabicCambodianHindiHmongJapanesePunjabRussianThaiRepresentative Name*