"Auto Accident Reporting Form - Mclean Hallmark Insurance Group Ltd."

ADVERTISEMENT
ADVERTISEMENT

Download "Auto Accident Reporting Form - Mclean Hallmark Insurance Group Ltd."

Download PDF

Fill PDF online

Rate (4.7 / 5) 20 votes
Moore-McLean
Insurance Group Ltd.
48 Yonge Street, Suite 900
Toronto, ON M5E 1G6
Tel: (416) 364-4000 TF: 888-404-0000
AUTO ACCIDENT REPORTING FORM
INSURER:
AGENT OR BROKER:
CLAIM NUMBER:
NAME OF INSURED:
RES. PHONE #:
BUS. PHONE NUMBER #:
POLICY NUMBER:
HOME ADDRESS:
BUSINESS ADDRESS:
VEHICLE
REGISTERED OWNER:
ADDRESS:
ACTUAL OWNER:
ADDRESS:
YEAR:
MAKE:
MODEL:
SERIAL/VIN:
LICENSE NO. &
PROVINCE:
MILEAGE:
DESCRIBE DAMAGE:
ESTIMATE OF
DAMAGE:
DRIVER
NAME OF DRIVER:
AGE:
STATE ANY PHYSICAL DISABILITY:
HOW LONG
DRIVING:
HOME ADDRESS:
BUS. ADDRESS:
RES. PHONE #:
BUS. PHONE #:
DRIVERS' LICENSE NUMBER:
PREVIOUS ACCIDENTS OR CONVICTIONS:
DATE OF ACCIDENT:
TIME:
□DAYLIGHT
□DUSK □DARK
LOCATION OF ACCIDENT:
PURPOSE OF TRIP AT TIME OF ACCIDENT:
WEATHER CONDITIONS:
ROAD CONDITIONS:
YOUR SPEED:
DIRECTION:
OTHER DRIVER'S SPEED:
DIRECTION:
POLICE INVESTIGATION BY:
CHARGES LAID:
OFFICER NAME:
BADGE NUMBER:
DEPT. OR CITY:
REPORT NUMBER:
HAD YOU CONSUMED ANY ALCOHOL OR
WHO WAS RESPONSIBLE FOR THE ACCIDENT - REASON:
DRUGS PRIOR TO THE ACCIDENT?:
□YES
□NO
PROPERTY OF OTHERS
NAME OF INSURED:
PHONE NUMBER:
NAME OF INSURED:
ADDRESS:
ADDRESS:
YEAR/MAKE/MODEL OF VEHICLE:
LICENSE NUMBER:
YEAR/MAKE/MODEL OF VEHICLE:
NAME OF INSURER:
POLICY NUMBER:
NAME OF INSURER:
DESCRIPTION OF DAMAGE:
DESCRIPTION OF DAMAGE:
WHERE VEHICLE CAN BE INSPECTED:
WHERE VEHICLE CAN BE INSPECTED:
NAME OF DRIVER:
PHONE NUMBER:
NAME OF DRIVER:
1
M o o r e - M c L e a n I n s u r a n c e G r o u p L t d .
2 0 1 3
Moore-McLean
Insurance Group Ltd.
48 Yonge Street, Suite 900
Toronto, ON M5E 1G6
Tel: (416) 364-4000 TF: 888-404-0000
AUTO ACCIDENT REPORTING FORM
INSURER:
AGENT OR BROKER:
CLAIM NUMBER:
NAME OF INSURED:
RES. PHONE #:
BUS. PHONE NUMBER #:
POLICY NUMBER:
HOME ADDRESS:
BUSINESS ADDRESS:
VEHICLE
REGISTERED OWNER:
ADDRESS:
ACTUAL OWNER:
ADDRESS:
YEAR:
MAKE:
MODEL:
SERIAL/VIN:
LICENSE NO. &
PROVINCE:
MILEAGE:
DESCRIBE DAMAGE:
ESTIMATE OF
DAMAGE:
DRIVER
NAME OF DRIVER:
AGE:
STATE ANY PHYSICAL DISABILITY:
HOW LONG
DRIVING:
HOME ADDRESS:
BUS. ADDRESS:
RES. PHONE #:
BUS. PHONE #:
DRIVERS' LICENSE NUMBER:
PREVIOUS ACCIDENTS OR CONVICTIONS:
DATE OF ACCIDENT:
TIME:
□DAYLIGHT
□DUSK □DARK
LOCATION OF ACCIDENT:
PURPOSE OF TRIP AT TIME OF ACCIDENT:
WEATHER CONDITIONS:
ROAD CONDITIONS:
YOUR SPEED:
DIRECTION:
OTHER DRIVER'S SPEED:
DIRECTION:
POLICE INVESTIGATION BY:
CHARGES LAID:
OFFICER NAME:
BADGE NUMBER:
DEPT. OR CITY:
REPORT NUMBER:
HAD YOU CONSUMED ANY ALCOHOL OR
WHO WAS RESPONSIBLE FOR THE ACCIDENT - REASON:
DRUGS PRIOR TO THE ACCIDENT?:
□YES
□NO
PROPERTY OF OTHERS
NAME OF INSURED:
PHONE NUMBER:
NAME OF INSURED:
ADDRESS:
ADDRESS:
YEAR/MAKE/MODEL OF VEHICLE:
LICENSE NUMBER:
YEAR/MAKE/MODEL OF VEHICLE:
NAME OF INSURER:
POLICY NUMBER:
NAME OF INSURER:
DESCRIPTION OF DAMAGE:
DESCRIPTION OF DAMAGE:
WHERE VEHICLE CAN BE INSPECTED:
WHERE VEHICLE CAN BE INSPECTED:
NAME OF DRIVER:
PHONE NUMBER:
NAME OF DRIVER:
1
M o o r e - M c L e a n I n s u r a n c e G r o u p L t d .
2 0 1 3
ADDRESS:
ADDRESS:
PERSONS INJURED
NAME:
NAME:
NAME:
ADDRESS:
ADDRESS:
ADDRESS:
PHONE #:
AGE:
PHONE #:
AGE:
PHONE #:
AGE:
WITNESSES
NAME:
NAME:
NAME:
ADDRESS:
ADDRESS:
ADDRESS:
PHONE #:
PHONE #:
PHONE #:
IN WHICH CAR?
IN WHICH CAR?
IN WHICH CAR?
□ YOUR CAR
□ OTHER CAR #1
□ YOUR CAR
□ OTHER CAR #1
□ YOUR CAR
□ OTHER CAR #1
□ OTHER CAR #2
□ OTHER
□ OTHER CAR #2
□ OTHER
□ OTHER CAR #2
□ OTHER
ACCIDENT DESCRIPTION
DATE:
SIGNATURE OF DRIVER:
TO BE COMPLETED BY THE POLICYHOLDER
WHO IS THE PRINCIPAL DRIVER OF THE VEHICLE?
WHAT IS THE DRIVER’S RELATIONSHIP TO YOU?
WAS THE VEHICLE BEING USED WITH YOUR CONSENT?
LIEN OR MORTGAGE ON VEHICLE TO:
DATE:
SIGNATURE OF POLICYHOLDER:
PRIVACY
Some of the information you provide in this report may be personal. By completing and signing this form, you confirm that you have given us authority to use
and share this information with other insurance companies, counsel, or other people with an interest in this claim.
2 0 1 3
2
M o o r e - M c L e a n I n s u r a n c e G r o u p L t d .
Page of 2