"Auto Accident Report Form - Ahtky Insurance Agency"

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AHTKY INSURANCE AGENCY, LLC.
AUTO ACCIDENT REPORT RECORD
Please read carefully and be sure to keep this form in the glove compartment of your vehicle. If you
are involved in an accident, it is very important that you complete the backside of this form.
Remember – stay calm and take down all details of the accident
1. Check for Injuries
5. Protect Yourself
we will forward the report to
Check everyone involved to
Do not apologize for the
your insurance company’s
see if there are injuries.
accident or admit guilt to
claims department. Your
Move out of traffic to safety.
anyone, no matter who is “At
insurance company will then
Call 911 or have someone
Fault”. If there is an
assign an adjuster who will
else call 911 if there are
individual at the scene of the
thoroughly investigate the
injuries.
accident who can be an eye
accident in order to settle
witness, be sure to obtain
the claim.
the person’s name, address
2. Accident & Scene
Pull to the side of the road (if
and phone number.
9. Complete SR-1 Form
possible). Warn passing
In California, if an accident
drivers of the accident by
6. Accident Facts
involves bodily injury, death
using triangles, flares, cones
It is very important for the
or more than $750 property
or any other safety devices
insurance company to
damage (regardless of who
in your vehicle. Watch for
determine who is “At Fault”.
is “At Fault”), a SR-1 form is
any gasoline leaks – clear
Write down the description
required by the Department
the area if gasoline is
of the accident, date, time
of Motor Vehicles (DMV).
leaking. Stay off the street.
and location of accident,
The SR-1 must be filed
speed of the vehicle(s)
within 10 days from the
involved, road conditions, if
accident date and is
3. Alert the Police
Call the police or ask a
there were stop lights or
certification that you were
passenger to do it. Only
stop signs, etc. Use the
insured at the time of the
provide detailed information
back of this form to record
accident. You may get the
that you know. Retain the
all accident details.
SR-1 form from the DMV or
police report number if a
AHTKY’s office located at:
report is made.
7. Take your Car to the
Body Shop
1451 W. Artesia Blvd.,
4. Exchange Information
If you are unable to drive
suite A
Whether the accident is “At
your vehicle to a body shop,
Gardena, CA 90248
Fault” or “Not At Fault”
please call a tow company
Phone: (310) 516-0110
exchange information with
for assistance. Do not
Fax:
(310) 516-0381
the other driver(s) involved.
repair your car until you
Obtain the other driver’s
have contacted your agent
Our office hours are 9:00
or AHTKY Insurance
name, address, phone
a.m. to 5:00 p.m., Monday
Agency to discuss this
number, drivers license
through Friday. There is a
number, insurance company
matter.
24-hour answering service
name, year, make and
for your convenience if you
model of other vehicle(s),
8. Contact AHTKY
wish to leave a message.
vehicle I.D. #, and license
Insurance Agency
Your call will be returned as
plate number. You should
Immediately
soon as possible.
provide the same
Please contact our office as
information to the other
soon as possible. When we
driver(s).
receive your accident report,
10/17/2014
AHTKY INSURANCE AGENCY, LLC.
AUTO ACCIDENT REPORT RECORD
Please read carefully and be sure to keep this form in the glove compartment of your vehicle. If you
are involved in an accident, it is very important that you complete the backside of this form.
Remember – stay calm and take down all details of the accident
1. Check for Injuries
5. Protect Yourself
we will forward the report to
Check everyone involved to
Do not apologize for the
your insurance company’s
see if there are injuries.
accident or admit guilt to
claims department. Your
Move out of traffic to safety.
anyone, no matter who is “At
insurance company will then
Call 911 or have someone
Fault”. If there is an
assign an adjuster who will
else call 911 if there are
individual at the scene of the
thoroughly investigate the
injuries.
accident who can be an eye
accident in order to settle
witness, be sure to obtain
the claim.
the person’s name, address
2. Accident & Scene
Pull to the side of the road (if
and phone number.
9. Complete SR-1 Form
possible). Warn passing
In California, if an accident
drivers of the accident by
6. Accident Facts
involves bodily injury, death
using triangles, flares, cones
It is very important for the
or more than $750 property
or any other safety devices
insurance company to
damage (regardless of who
in your vehicle. Watch for
determine who is “At Fault”.
is “At Fault”), a SR-1 form is
any gasoline leaks – clear
Write down the description
required by the Department
the area if gasoline is
of the accident, date, time
of Motor Vehicles (DMV).
leaking. Stay off the street.
and location of accident,
The SR-1 must be filed
speed of the vehicle(s)
within 10 days from the
involved, road conditions, if
accident date and is
3. Alert the Police
Call the police or ask a
there were stop lights or
certification that you were
passenger to do it. Only
stop signs, etc. Use the
insured at the time of the
provide detailed information
back of this form to record
accident. You may get the
that you know. Retain the
all accident details.
SR-1 form from the DMV or
police report number if a
AHTKY’s office located at:
report is made.
7. Take your Car to the
Body Shop
1451 W. Artesia Blvd.,
4. Exchange Information
If you are unable to drive
suite A
Whether the accident is “At
your vehicle to a body shop,
Gardena, CA 90248
Fault” or “Not At Fault”
please call a tow company
Phone: (310) 516-0110
exchange information with
for assistance. Do not
Fax:
(310) 516-0381
the other driver(s) involved.
repair your car until you
Obtain the other driver’s
have contacted your agent
Our office hours are 9:00
or AHTKY Insurance
name, address, phone
a.m. to 5:00 p.m., Monday
Agency to discuss this
number, drivers license
through Friday. There is a
number, insurance company
matter.
24-hour answering service
name, year, make and
for your convenience if you
model of other vehicle(s),
8. Contact AHTKY
wish to leave a message.
vehicle I.D. #, and license
Insurance Agency
Your call will be returned as
plate number. You should
Immediately
soon as possible.
provide the same
Please contact our office as
information to the other
soon as possible. When we
driver(s).
receive your accident report,
10/17/2014
ACCIDENT REPORT
If an accident occurs, remember to stay calm and exchange the following information from all parties
involved regardless of who is at fault.
Your Information:
Policy Holder’s Name:
Insurance Company:
Policy #:
Date of Accident:
Time of Accident:
Location of Accident - Street:
Cross Street:
City / State:
Description of Accident:
Driver:
DOB:
DL #:
Driver’s Relationship to Insd:
Injuries:
Phone: Home ___________________
Work
Cell _______________
Year, Make & Model of Your Car: ___________________________________________________
Vehicle License Plate Number:
____________________ Color:
________________________
Damage:
Driveable?:
Airbags deploy?:
Location of car if not driveable:
Passengers:
Phone H/B:
Police Report:
Department:
Report #:
Other Party Information:
Driver of the other car:
___________________________ Drivers License: ________________
Address: ______________________________________________________________________
Phone: Home ___________________
Work
Cell _______________
Registered Owner of Vehicle: ______________________________________________________
Address of Registered Owner: _____________________________________________________
Year, Make & Model of Other Car: __________________________________________________
Vehicle License Plate Number:
____________________ Color:
________________________
Passengers:
Phone H/B:
Insurance Company:
_______________________________ Policy No. __________________
Agent’s Name & Phone: __________________________________________________________
Witness:
Name: ________________________________________________________________________
Witness Address & Phone: ________________________________________________________
N
Please use the layout below to diagram the accident.
The following questions should help in completing the diagram.
W
E
• Which direction were
S
you going?
• Which direction was
the other car going?
• Were you stopped or
moving at the time of the
accident?
• How fast were you
going?
• Were there any stop
signs or signals?
• How many lanes were
there?
10/17/2014
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