PDF Driver's Accident Report Form - Peoples Place

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´╗┐Driver's Accident Report Form

IN THE EVENT OF AN ACCIDENT

NONPROFIT / INSURED Driver ? Complete all items to the best of your ability, sign and date page 3, and immediately give it to your supervisor. Supervisor ? Fax this Driver's Accident Report form to your insurance broker immediately.

BROKER ? Refer to our website for instructions on claim reporting.

If a claim needs to be reported after business hours or on the weekend, call (866) 718-1947. This number is reserved for true claims emergencies after business hours and weekends.

Driver/Vehicle Information

Name of Driver (first and last) Driver's Address ? Street Name of Nonprofit / Employer Nonprofit/Employer Contact Name Nonprofit / Employer Address ? Street Make of Nonprofit's Vehicle Damage to Nonprofit's Vehicle:

City

City Body Type

Driver's Age

Driver License No.

State

State

Zip

Telephone No.

( )

ANI/NIAC Policy Number

Contact Email Address

State

Zip

Year

License Plate #

Telephone No.

( )

V.I.N. (last four digits)

Accident Information

Date of Accident

Day of Week (circle one)

Mon Tue Wed Thurs Fri Sat Sun

On what street were you driving?

On what street was other vehicle driving?

Police Report?

If yes, name of reporting officer

Yes

No

Witness #1 Name (first and last)

Witness #2 Name (first and last)

Description of Accident (include weather and road conditions):

Time of Accident AM / PM

Agency

Location - Street or Highway & City

Direction (circle one) N S E W

Direction (circle one) N S E W

Citation/Report #

Speed (approximate) Speed (approximate)

Telephone No.

( )

Telephone No.

( )

Email Address Email Address

Serving ...

(Use the back of this sheet if additional space is needed; please use the diagrams on page 3 to draw the accident)

Passenger(s) in Your Vehicle (attached additional pages if needed)

Name (first and last)

Telephone No.

( )

Name

Telephone No.

( )

Name

Telephone No.

( )

Ambulance called to scene? Name of doctor or hospital

Yes

No

Other Vehicle Involved

Name of Driver (first and last)

Email Address Email Address Email Address

Age Injuries? Yes No

Age Injuries? Yes No

Age Injuries? Yes No

Driver License No.

State

Address - Street Name of Vehicle Owner (if different than above) Name of Insurance Company Year/Make of Vehicle

City/State/Zip Body Type

Policy #

Telephone No.

Email Address

( )

Telephone No.

Email Address

( )

Telephone No.

( )

License Plate No.

State

Damage to Vehicle:

Passenger's Name (first and last) Passenger's Name (first and last)

Other Vehicle Involved (if any)

Name of Driver (first and last)

Telephone No.

( )

Telephone No.

( )

Email Address Email Address

Age Injuries? Yes No

Age Injuries? Yes No

Driver License No.

State

Address - Street Name of Vehicle Owner (if different than above) Name of Insurance Company Year/Make of Vehicle

City/State/Zip Body Type

Policy #

Telephone No.

Email Address

( )

Telephone No.

Email Address

( )

Telephone No.

( )

License Plate No.

State

Damage to Vehicle:

Passenger's Name (first and last) Passenger's Name (first and last)

Telephone No.

( )

Telephone No.

( )

Email Address Email Address

Age Injuries? Yes No

Age Injuries? Yes No

LC-DAR 04_12

Pg 2 of 3

On the diagrams below, please draw the accident. (Be sure to include any stop signs or traffic signals.)

Legend: V 1 X Your Vehicle V 2 X Other Vehicle V 3 X Other Vehicle (if any)

N

? W ? ? E

?

S

On the overhead diagrams below, please indicate the location of damage to your vehicle, if any.

back ------------ VAN ------------ front

back ------------ AUTO ----------- front

SIGNATURE OF DRIVER

LC-DAR 04_12

DATE

Pg 3 of 3

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