ACCIDENT REPORT
Insured
Policy Number
ACCIDENT INFORMATION
Date of Accident
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Location of Accident
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Responding Police Department
Police Report Number
Accident Facts (Describe how accident occurred)
INSURED VEHICLE INFORMATION
INSURED VEHICLE - (vehicle #/owner's name/year/make/model/VIN #)
INSURED DRIVER'S INFORMATION - (name, D/L #, address, phone)
DESCRIPTION OF DAMAGE TO INSURED VEHICLE
OTHER VEHICLE INFORMATION
OTHER VEHICLE - (year/make/model/tag #/insurance co name/policy #)
OTHER OWNER/DRIVER'S INFORMATION - (name, D/L #, address, phone)
DESCRIPTION OF DAMAGE TO ADVERSE VEHICLE
INJURED PARTIES
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
INJURIES
INVOLVEMENT
WITNESSES OR PASSENGERS
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
INVOLVEMENT
ADDITIONAL INFORMATION
REMARKS
NAME OF PERSON REPORTING ACCIDENT
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
FILE UPLOADS
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Applicable in Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
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