Accident Form
SEND US YOUR ACCIDENT INFORMATION
IF YOU HAVE AN ACCIDENT, use this form to record the facts about the accident, including names and address of all parties involved, and any witnesses to the accident.

Thank you.

(* = required)

* Denotes required fields and/or sections
 User: INSURED
* Your Name:
* Phone: * Your email:
- FORM CONTENTS-
I. Policyholder Information
II. Your Insured Vehicle
III. General
IV. Property Damaged (Not Your Vehicle)
V. Injured Parties [optional]
VI. Witnesses or Passengers [optional]
Please provide us with as much information as possible. It will help us to expedite the claim.
Thank you!
I. Policyholder Information
( 1 ) •••• POLICYHOLDER INFO ••••
( 2 ) •••• POLICYHOLDER'S PHONE(S) ••••
* Name:
* Residence: (  ) -       
* Policy #:       Business: (  ) -       
           Cellular: (  ) -       
( 3 ) •••• REMARKS ••••
II. Your Insured Vehicle
( 4 ) •••• VEHICLE ••••
( 5 ) •••• VEHICLE I.D. ••••
* Year:
* Plate Number:
* State:
* Make:
* Model:
( 6 ) •••• OWNER INFO ••••
( 7 ) •••• OWNER'S PHONE(S) ••••
* Name:
* Residence: (  ) - 
* Address:
      Business: (  ) - 
( 8 ) •••• DRIVER INFO ••••
( 9 ) •••• DRIVER'S PHONE(S) ••••
Name:
Residence: (  ) - 
Address:
   Business: (  ) - 
 [Check if Same as Owner]
( 10 ) •••• DRIVER I.D. ••••
( 11 ) •••• VEHICLE USAGE ••••
* Relation to Insured (Employee, Family, etc.):
* Date of Birth:
* License Number:
         * State: 
 Purpose of Use:
* Used With Permission?
Yes          No
( 12 ) •••• DESCRIBE DAMAGE ••••
* 
* Is the Vehicle Drivable?
Yes          No
 If Not Drivable, Where is the Vehicle Located?
III. General
( 13 ) •••• TIME OF ACCIDENT ••••
( 14 ) •••• LOCATION OF ACCIDENT ••••
* Date:
* [Include City and State]
( 15 ) •••• DESCRIPTION OF ACCIDENT ••••
* 
( 16 ) •••• POLICE DEPARTMENT ••••
( 17 ) •• RESULTING VIOLATIONS/CITATIONS ••
* Authority:
* [Describe]
* Report #:
IV. Property Damaged (Not Your Vehicle)
( 18 ) •••• PROPERTY DESCRIPTION ••••
( 19 ) •••• INSURANCE COMPANY ••••
  [If Auto, year, make, model, plate #]
  
( 20 ) •••• OWNER INFO ••••
( 21 ) •••• OWNER'S PHONE(S) ••••
  Name:
  Residence: (  ) - 
  Address:
     Business: (  ) - 
( 22 ) •••• OTHER DRIVER INFO ••••
( 23 ) •••• OTHER DRIVER'S PHONE(S) ••••
Name:
Residence: (  ) - 
Address:
   Business: (  ) - 
 [Check if Same as Owner]
( 24 ) •••• DRIVER'S LICENSE ••••
  Number:
( 25 ) •••• DESCRIBE DAMAGE ••••
  
V. Injured Parties
( 26 ) •••• PERSONAL INFO ••••
( 27 ) •••• DESCRIBE INJURY ••••
(A)   Name:
(A) 
Address:
Phone:
(  ) -    Age: 
Injured
was:
Pedestrian  In Your Car
In Other Car
(B)   Name:
(B) 
Address:
Phone:
(  ) -    Age: 
Injured
was: 		Pedestrian  In Your Car
In Other Car
VI. Witnesses or Passengers
( 28 ) •••• PERSONAL INFO ••••
( 29 ) •••• OTHER (SPECIFY) ••••
(A)   Name:
(A) 
Address:
Phone:
(  ) - 
Located:
In Your Car In Other Car
(B)   Name:
(B) 
Address:
Phone:
(  ) - 
Located:
In Your Car In Other Car
 
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