REPORT OF ACCIDENT - GEICO
Instructions
The Accident Report is for you to document what happened. Please include the name of GEICO insured, your claim number, and complete details related to the accident, then sign and date the form.
(Form Below)
GOVERNMENT EMPLOYEES INSURANCE COMPANIES
GEICO INSURED
REPORT OF ACCIDENT
YOUR NAME
ADDRESS
(NUMBER)
(STREET)
(CITY)
NAME AND ADDRESS OF EMPLOYER
ARE YOU MARRIED? IF YES, G I V E FULL NAME OF SPOUSE:
YES
NO
MAKE OF OUR INSURED"S AUTO
YEAR
NAME AND ADDRESS OF OUR INSURED DRIVER
MODEL
WHAT COMPANY(S) INSURES YOUR AUTOMOBILE
NAME OF COMPANY (S) PHONE #
DATE OF ACCIDENT MAKE OF YOUR AUTO
TIME YEAR
PLACE OF ACCIDENT M.
MODEL
NAME AND ADDRESS OF REGISTERED OWNER NAME AND ADDRESS OF DRIVER
AGE (STATE)
GEICO CLAIM #
OCCUPATION
(ZIP)
(E-MAIL)
PHONE NO.
HOME BUSINESS
LIC NO DRIVER"S LICENSE #
POLICY NO. CLAIM #
STATE
AGE
DOES THE POLICY CONTAIN MEDICAL COVERAGE FOR MEDICAL EXPENSES?
YES
NO
LIC. NO.
STATE
DRIVER'S LICENSE #
AGE
WAS DRIVER ON
ERRAND FOR OWNER?
YES
NO
IF YES, FOR WHAT PURPOSE?
NAME, ADDRESS, AND TELEPHONE NUMBER OF OCCUPANTS OF YOUR AUTOMOBILE:
NAME
ADDRESS
TELEPHONE NO.
1 2 3 4 WERE YOU HURT? YES NO WAS ANYONE HURT? YES NO IF SO, G I V E NAME, ADDRESS AND TEL. NO. OF OTHER PERSONS INJURED:
NAME
ADDRESS
1 2 3 4. 5 NATURE OF YOUR INJURIES NAME AND ADDRESS OF DOCTOR NAMES AND ADDRESSES OF ALL WITNESSES (OTHER THAN OCCUPANTS OF YOUR CAR):
TEL. NO.
SEAT BELTS
IN USE?
YES
NO
NAME
ADDRESS
IF AFTER DARK, WERE ALL VEHICLES LIGHTED?
YES
NO
CONDITION OF ROAD
(PLEASE COMPLETE OTHER SIDE)
C-22 (08-11)
WEATHER CONDITONS
STATE FULL DETAILS OF HOW THE ACCIDENT HAPPENED:
WHERE CAN CAR BE SEEN DURING THE DAY? LIST THE AREAS OF YOUR CAR WHICH WERE DAMAGED IN THE ACCIDENT:
DESCRIBE DAMAGED PROPERTY OTHER THAN YOUR AUTO
ARE YOU MAKING A CLAIM?
AGAINST WHOM?
YES
NO
DID YOU REPORT THE ACCIDENT TO POLICE?
WHERE? (DEPT. ADDRESS)
YES
NO
WAS ANYONE CHARGED?
WHO
YES
NO
DRAW A SKETCH OF THE ACCIDENT USING THIS DIAGRAM:
FOR WHAT AMOUNT? $
CHARGES
Show by arrow in this circle which way is North.
SIGNATURE DATE
Please label autos, stop signs, traffic signals, objects, street names, etc.
C-22 (08-11)
................
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