Auto Accident Report Form



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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