Auto Accident Report Form

Auto Accident Report Form Keep In Your Glove Box

POLICY HOLDER / Name:______
Address:______
/ Policy No:______
Business Phone No:-______
INSURED
VEHICLE,
DRIVER
AND USE / Tractor-Bus: Year______Make:______Serial No:______
Trailer- Bus: Year______Make:______Serial No:______
Owner of Above Tractor:______
Was equipment being operated about business of Assured:______
Name of Driver:______
Address:______
Driver's Licence No:______/ Lic. No:______Prov.:______
Lic. No:______Prov.:______
Trailer:______
Other Insurance Available:______
______
Phone No:______
Age:______
No. of Hours on Duty:______
CARGO
LOSS / Type of loss and commodity:______
PresentLocation:______/ Bill of Lading Enclosed:
No______Yes______
DETAILS
OF
ACCIDENT / Date:______19______Time:______am/pm______
Place:______
Police Report Made To:______City - Officers Number______
Any Charges Laid:______
What Charge:______/ WeatherConditions______
Conditions of Road:______
City orTown:______
Province:______
AgainstWhom:______
DAMAGE
TO
VEHICLE
OF
POLICY
HOLDER / COLLISION:______FIRE:______THEFT:______
Present Location of Assured'sVehicle?______
Assureds Estimate of Damage: ______
Can Assured Complete Repairs?______Were Temporary Repairs Made:______/ OTHER:______
Truck:______Tractor:______Trailer:______Bus:______
Amount:______
DAMAGE
TO
PROPERTY
OF OTHERS / Owner of Vehicle:______
Address:______
Licence No:______Phone______
Damage:______
Insurance Company:______
Owner of Vehicle:______
Address:______
Licence No:______Phone______
Damage:______
Insurance Company:______/ Driver of Vehicle:______
Year and Make of Vehicle:______
Licence No:______
Policy No:______
Province:______
Driver of Vehicle:______
Year and Make of Vehicle:______
Licence No:______
Policy No:______
Province:______
INJURED / (1)
Name:______
Address:______
Phone:______Age:______
Injuries:______
Doctor:______
Hospital:______/ (2)
Name:______
Address:______
Phone:______Age:______
Injuries:______
Doctor:______
Hospital:______/ (3)
Name:______
Address:______
Phone:______Age:______
Injuries:______
Doctor:______
Hospital:______
OCCUPANTS OF INSURED VEHICLE
NAME:______/ ADDRESS:______/ PHONE:______
NAME:______/ ADDRESS:______/ PHONE:______
OCCUPANTS OF OTHER VEHICLE:
NAME:______/ ADDRESS:______/ PHONE:______
NAME:______/ ADDRESS:______/ PHONE:______
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:______
THE
ACCIDENT / POLICYHOLDER'S VEHICLE:
SPEED:
Before The Accident:______km/h
At Instant of Accident:______per hour
LIGHTS:______
( ON - OFF - DIM - BRIGHT)
Which Side of Road______Warning:______
Direction Travelled:______/ OTHER VEHICLE:
SPEED:
Before The Accident:______km/h
At Instant of Accident:______per hour
LIGHTS:______
( ON - OFF - DIM - BRIGHT)
Which Side of Road______Warning:______
Direction Travelled:______
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:______Wire:______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