Auto Accident Report Form - ExcelTemple



Accident Report Form?TemplatePOLICY HOLDERName:_______________________________________________________________________________Address:______________________________________________________________________________Policy No:_________________________________________Business Phone No:-_________________________________INSUREDVEHICLE,DRIVERAND USETractor-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:_______________________________CARGOLOSSType of loss and commodity:_____________________________________________________________PresentLocation:________________________________________________________________________Bill of Lading Enclosed:No___________ Yes_________________DETAILSOFACCIDENT 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:______________________________________DAMAGETOVEHICLEOFPOLICYHOLDERCOLLISION:____________________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:__________________________________________DAMAGETOPROPERTYOF OTHERSOwner 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 VEHICLENAME:_______________________________________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:________________THEACCIDENTPOLICYHOLDER'S VEHICLE:SPEED:Before The Accident:_______________________________km/hAt Instant of Accident:___________________________per hourLIGHTS:_____________________________________________ ( ON - OFF - DIM - BRIGHT)Which Side of Road_______________Warning:_____________Direction Travelled:____________________________________OTHER VEHICLE:SPEED:Before The Accident:_______________________________km/hAt Instant of Accident:___________________________per hourLIGHTS:_____________________________________________ ( 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:________________ ................
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