Auto Accident Report Form - l.b5z.net
Auto Accident Report Form Keep In Your Glove Box
|POLICY HOLDER |Name:_______________________________________________________________________________ |Policy No:_________________________________________ |
| |Address:______________________________________________________________________________ |Business Phone No:-_________________________________ |
|INSURED |Tractor-Bus: Year_________Make:__________________Serial No:______________________________ |Lic. No:_______________________Prov.:______________ |
|VEHICLE, |Trailer- Bus: Year_________Make:__________________Serial No:______________________________ |Lic. No:_______________________Prov.:______________ |
|DRIVER |Owner of Above Tractor:________________________________________________________________ |Trailer:____________________________________________ |
|AND USE |Was equipment being operated about business of Assured:______________________________________ |Other Insurance Available:____________________________ |
| |Name of Driver:________________________________________________________________________ |__________________________________________________ |
| |Address:__________________________________________________________________________________________________|Phone No:_________________________________________ |
| |_________________________________________________________________ |Age:______________________________________________ |
| |Driver's Licence No:____________________________________________________________________ |No. of Hours on Duty:_______________________________ |
|CARGO |Type of loss and commodity:_____________________________________________________________ |Bill of Lading Enclosed: |
|LOSS |PresentLocation:________________________________________________________________________ |No___________ Yes_________________ |
|DETAILS | Date:____________________________ 19_________Time:____________________am/pm__________ |WeatherConditions__________________________________ |
|OF |Place:________________________________________________________________________________ |Conditions of Road:__________________________________ |
|ACCIDENT |Police Report Made To:________________________City - Officers Number_______________________ |City orTown:_______________________________________ |
| |Any Charges Laid:_____________________________________________________________________ |Province:__________________________________________ |
| |What Charge:__________________________________________________________________________ |AgainstWhom:______________________________________ |
|DAMAGE | | |
|TO |COLLISION:____________________FIRE:______________________THEFT:___________________ |OTHER:__________________________________________ |
|VEHICLE | | |
|OF |Present Location of Assured'sVehicle?______________________________________________________ |Truck:____________Tractor:__________________________Trailer:___|
|POLICY |Assureds Estimate of Damage: ___________________________________________________________ |_________Bus:____________________________ |
|HOLDER |Can Assured Complete Repairs?_____________Were Temporary Repairs Made:____________________ |Amount:__________________________________________ |
| |Owner of Vehicle:______________________________________________________________________ |Driver of Vehicle:___________________________________ |
| |Address:______________________________________________________________________________ |Year and Make of Vehicle:__________________________ |
|DAMAGE |Licence No:___________________________________________Phone___________________________ |Licence No:________________________________________ |
|TO |Damage:______________________________________________________________________________ |Policy No:_________________________________________ |
|PROPERTY |Insurance Company:____________________________________________________________________ |Province:__________________________________________ |
|OF OTHERS |Owner of Vehicle:______________________________________________________________________ |Driver of Vehicle:___________________________________ |
| |Address:______________________________________________________________________________ |Year and Make of Vehicle:__________________________ |
| |Licence No:___________________________________________Phone___________________________ |Licence No:________________________________________ |
| |Damage:______________________________________________________________________________ |Policy No:_________________________________________ |
| |Insurance Company:____________________________________________________________________ |Province:__________________________________________ |
| |(1) |(2) |(3) | |
| |Name:____________________________________ |Name:____________________________________ |Name:____________________________________ | |
|INJURED |Address:_____________________________________________|Address:_____________________________________________|Address:_____________________________________________| |
| |______________________________ |______________________________ |______________________________ | |
| |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:________________ |
| | | |
|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:________________ |
| |POLICYHOLDER'S VEHICLE: |OTHER VEHICLE: |
| |SPEED: |SPEED: |
| |Before The Accident:_______________________________km/h |Before The Accident:_______________________________km/h |
|THE |At Instant of Accident:___________________________per hour |At Instant of Accident:___________________________per hour |
|ACCIDENT |LIGHTS:_____________________________________________ |LIGHTS:_____________________________________________ |
| |( ON - OFF - DIM - BRIGHT) |( ON - OFF - DIM - BRIGHT) |
| |Which Side of Road_______________Warning:_____________ |Which Side of Road_______________Warning:_____________ |
| |Direction Travelled:____________________________________ |Direction Travelled:____________________________________ |
|DRIVER'S STATEMENT OF HOW ACCIDENT OCCURRED: | | |
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|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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|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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