9
Jun

Accident Information Checklist

Accident Information Checklist

Name of Other Driver

Address_______________________________________________________

Year, Make, Model of Vehicle_______________________________________

License Plate & VIN (Vehicle Identification Number)

_____________________________________________________________

Insurer’s Name, Address, and Phone Number

______________________________________________________________

______________________________________________________________

Passenger Information

Passenger #1__________________________________________________

Passenger #2__________________________________________________

Witness Information

Witness #1____________________________________________________

Witness #2____________________________________________________

Crash Location (Include city/town, street)

_____________________________________________________________

Crash Conditions (Include date, time of day, weather, traffic, and road conditions as well as any relevant roadway features, such as type of intersection or stop light.)

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Brief Description of Accident

_____________________________________________________________

_____________________________________________________________

Property Damage Information (Describe damages to all vehicles, including your own.)

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

-Robert Catalano