"Auto Accident Report Form"

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Auto Accident Report Form
Keep In Your Glove Box
Name:_______________________________________________________________________________
Policy #:____________________________________
POLICY
Address:______________________________________________________________________________
Phone #:____________________________________
HOLDER
Vehicle: Year ________Make: _________________Serial #:______________________________
Lic. #:_______________________State:___________
INSURED
Vehicle: Year ________Make: _________________Serial #:______________________________
Lic. #:_______________________State:___________
VEHICLE,
Owner of Above Vehicle:________________________________________________________________
Trailer:______________________________________
DRIVER
Was equipment being operated about business of Insured:______________________________________
Other Insurance Available:_______________________
AND USE
Name of Driver:________________________________________________________________________
____________________________________________
Address:______________________________________________________________________________
Phone #:____________________________________
_____________________________________________________________________________________
Age:________________________________________
Driver's License #: __________________________________________________________________
#of Hours on Duty:___________________________
Type of loss and commodity: ____________________________________________________________
Bill of Lading Enclosed:
CARGO
Current Location: _______________________________________________________________________
No___________ Yes _________________
LOSS
Date: ___________________________ 20________ Time: ___________________am/pm_________
DETAILS
Place: _____________________________________________________________________________
Weather Conditions_____________________________
OF
Police Report Made To: ________________________________________________________________
Conditions of Road: ___________________________
ACCIDENT
Case Number: ____________________________ City - Officer's Number: ______________________
City or Town: ________________________________
Any Charge(s) Made: _________________________________________________________________
State: ___________________________________
What Charge(s):_______________________________________________________________________
Against Whom: _______________________________
DAMAGE
COLLISION: ___________________FIRE:______________________THEFT:___________________
OTHER: ___________________________________
TO
VEHICLE
Present location of Insured Vehicle? _____________________________________________________
Truck: ___________Tractor:_____________________
OF
Insured's Estimate of Damage: ___________________________________________________________
Trailer: ___________Bus:_______________________
POLICY
Can Insured Complete Repairs? ____________Were Temporary Repairs Made: ___________________
Amount: ___________________________________
HOLDER
Owner of Vehicle: _____________________________________________________________________
Driver of Vehicle: ___________________________
Address: _____________________________________________________________________________
Year and Make of Vehicle:______________________
License #:___________________________________________Phone___________________________
License # :___________________________________
DAMAGE
Damage: ______________________________________________________________________________
Policy #:___________________________________
TO
Insurance Company: ___________________________________________________________________
State: ______________________________________
PROPERTY
Owner of Vehicle: _____________________________________________________________________
Driver of Vehicle: ____________________________
OF
Address: _____________________________________________________________________________
Year and Make of Vehicle: _____________________
OTHERS
License # :___________________________________________Phone: ___________________________
License #: ___________________________________
Damage: ______________________________________________________________________________
Policy #: ___________________________________
Insurance Company: ___________________________________________________________________
State: _______________________________________
(1)
(2)
(3)
Name:____________________________________
Name:____________________________________
Name:____________________________________
Address:__________________________________
Address:__________________________________
Address:__________________________________
INJURED
_________________________________________
_________________________________________
_________________________________________
Phone: ____________________Age:___________
Phone: ____________________Age:___________
Phone: ____________________Age:___________
Injuries:__________________________________
Injuries:__________________________________
Injuries:__________________________________
Doctor:___________________________________
Doctor:___________________________________
Doctor:___________________________________
Hospital:__________________________________
Hospital:__________________________________
Hospital:__________________________________
Auto Accident Report Form
Keep In Your Glove Box
Name:_______________________________________________________________________________
Policy #:____________________________________
POLICY
Address:______________________________________________________________________________
Phone #:____________________________________
HOLDER
Vehicle: Year ________Make: _________________Serial #:______________________________
Lic. #:_______________________State:___________
INSURED
Vehicle: Year ________Make: _________________Serial #:______________________________
Lic. #:_______________________State:___________
VEHICLE,
Owner of Above Vehicle:________________________________________________________________
Trailer:______________________________________
DRIVER
Was equipment being operated about business of Insured:______________________________________
Other Insurance Available:_______________________
AND USE
Name of Driver:________________________________________________________________________
____________________________________________
Address:______________________________________________________________________________
Phone #:____________________________________
_____________________________________________________________________________________
Age:________________________________________
Driver's License #: __________________________________________________________________
#of Hours on Duty:___________________________
Type of loss and commodity: ____________________________________________________________
Bill of Lading Enclosed:
CARGO
Current Location: _______________________________________________________________________
No___________ Yes _________________
LOSS
Date: ___________________________ 20________ Time: ___________________am/pm_________
DETAILS
Place: _____________________________________________________________________________
Weather Conditions_____________________________
OF
Police Report Made To: ________________________________________________________________
Conditions of Road: ___________________________
ACCIDENT
Case Number: ____________________________ City - Officer's Number: ______________________
City or Town: ________________________________
Any Charge(s) Made: _________________________________________________________________
State: ___________________________________
What Charge(s):_______________________________________________________________________
Against Whom: _______________________________
DAMAGE
COLLISION: ___________________FIRE:______________________THEFT:___________________
OTHER: ___________________________________
TO
VEHICLE
Present location of Insured Vehicle? _____________________________________________________
Truck: ___________Tractor:_____________________
OF
Insured's Estimate of Damage: ___________________________________________________________
Trailer: ___________Bus:_______________________
POLICY
Can Insured Complete Repairs? ____________Were Temporary Repairs Made: ___________________
Amount: ___________________________________
HOLDER
Owner of Vehicle: _____________________________________________________________________
Driver of Vehicle: ___________________________
Address: _____________________________________________________________________________
Year and Make of Vehicle:______________________
License #:___________________________________________Phone___________________________
License # :___________________________________
DAMAGE
Damage: ______________________________________________________________________________
Policy #:___________________________________
TO
Insurance Company: ___________________________________________________________________
State: ______________________________________
PROPERTY
Owner of Vehicle: _____________________________________________________________________
Driver of Vehicle: ____________________________
OF
Address: _____________________________________________________________________________
Year and Make of Vehicle: _____________________
OTHERS
License # :___________________________________________Phone: ___________________________
License #: ___________________________________
Damage: ______________________________________________________________________________
Policy #: ___________________________________
Insurance Company: ___________________________________________________________________
State: _______________________________________
(1)
(2)
(3)
Name:____________________________________
Name:____________________________________
Name:____________________________________
Address:__________________________________
Address:__________________________________
Address:__________________________________
INJURED
_________________________________________
_________________________________________
_________________________________________
Phone: ____________________Age:___________
Phone: ____________________Age:___________
Phone: ____________________Age:___________
Injuries:__________________________________
Injuries:__________________________________
Injuries:__________________________________
Doctor:___________________________________
Doctor:___________________________________
Doctor:___________________________________
Hospital:__________________________________
Hospital:__________________________________
Hospital:__________________________________
OCCUPANTS OF INSURED VEHICLE
NAME:_______________________________________
ADDRESS:_________________________________________________
PHONE:________________
NAME:_______________________________________
ADDRESS:_________________________________________________
PHONE:________________
NAME:____________________________
OCCUPANTS OF OTHER VEHICLE:
NAME:_______________________________________
ADDRESS:_________________________________________________
PHONE:________________
NAME:_______________________________________
ADDRESS:_________________________________________________
PHONE:________________
IMPORTANT: INDEPENDENT WITNESSES: (Include names of bystanders who saw accident, or heard any statements made)
NAME:_______________________________________
ADDRESS:_________________________________________________
PHONE:________________
NAME:_______________________________________
ADDRESS:_________________________________________________
PHONE:________________
NAME:_______________________________________
ADDRESS:_________________________________________________
PHONE:________________
POLICYHOLDER'S VEHICLE:
OTHER VEHICLE:
SPEED:
SPEED:
Before The Accident: _______________________________mph
Before The Accident: _______________________________mph
THE
At Instant of Accident: ___________________________per hour
At Instant of Accident: ___________________________per hour
LIGHTS:_____________________________________________
LIGHTS:_____________________________________________
ACCIDENT
( ON - OFF - DIM - BRIGHT)
( ON - OFF - DIM - BRIGHT)
Which Side of Road _______________Warning:_____________
Which Side of Road ______________Warning:_____________
Direction Traveled:____________________________________
Direction Traveled:____________________________________
DRIVER'S STATEMENT OF HOW ACCIDENT OCCURRED:
What part of your vehicle and what part of other car were first in touch? _____________________________________________________________________________
Whom do you consider is responsible?_________________________________________________________________________________________________________
Date Signed: ____________________________________________Signature of Driver:__________________________________________________________________
Date Reported:__________________ How Reported: Phone_____ Email_____ Fax ______Letter ______ In Person _______Time ______
Attach a diagram to further explain accident, show points of compass, name of streets, direction of cars and position of cars at instant of accident
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