Motor Vehicle Accident Report
Overview
Automobile liability claims arise out of the injury to others or damage to property of others resulting from the use, maintenance, or operation of an insured vehicle. Hired and non-owned vehicles also fit into this category, as your policy may provide coverage based on agreements and contracts.Automobile physical damage claims include, but may not be limited to, collision, fire, glass breakage, vandalism, and other perils. Follow the instructions below when this type of loss occurs.
Instructions
Complete the report form and submit it to McGriff Claims Central as soon after the incident as possible. Contact law enforcement after the incident occurs, especially if there are injuries, death or significant property damage related to the accident. Cooperate with law enforcement officials. Seek medical attention and/or secure first aid for anyone injured.Do not admit fault or offer any payment. Do not discuss the details of the accident with anyone other than law enforcement, identified representative of the insurance company or a representative of your company.Report the accident to your employer immediately. Record accident details on the Motor Vehicle Accident Report Form. Obtain the names, phone numbers and addresses of all other passengers/parties involved in the accident including any witnesses. Deliver completed form to immediate supervisor as instructed.Take photos of the accident scene and vehicles if possible. Report the loss to McGriff by calling or faxing the information. Refer to the account service team sheet for phone and fax numbers. Once the loss is reported, you will be instructed how to proceed. Failure to report the claim may void your coverage for that claim.If the vehicle is inoperable, ensure arrangements have been made for towing and delivery of cargo, if necessary.If the vehicle you are operating is a rental vehicle, complete the accident report information required by the rental car dealer. Keep a copy of the report to send it to McGriff. You should routinely inspect a rental vehicle, when picking it up and returning it, to note any damage to the vehicle.If you are served a Summons or Complaint (suit papers), you must notify McGriff immediately. These are legal documents that require a timely response. Failure to do so may result in a default judgment against your company.
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Insured Details
Insured/Company Name
*
Report Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Contact Name
*
Contact Phone Number
*
Please enter a valid phone number.
Type of Claim Being Reported
Liability
Physical Damage
Cargo
Pollution
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Incident Details
Please select all that are applicable to this incident.
Injury occurred
Cargo/property was damaged
Witnesses are available
A lawsuit has been filed
Description of Incident
*
Date of Incident (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Time Incident Occurred
Hour Minutes
AM
PM
AM/PM Option
Street Address of Incident
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Specific Location of Incident (i.e., kitchen, parking lot, etc.)
Weather Conditions (wet, dry, etc.):
Please upload any photos/videos from the incident.
Browse Files
Drag and drop files here
Choose a file
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Responding police/authority
Officer and Report #
Type of violation(s) issued and to whom
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Your Vehicle (Company/Insured) Details
Please provide information about your vehicle.
Driver Details
Name
*
Phone Number
Please enter a valid phone number.
License Number
Date of Birth (mm/dd/yyyy)
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vehicle Details
Year
*
Make
*
Model
*
VIN (last four digits)
Location of Insured Vehicle
Damage to Insured Vehicle
*
Vehicle Towed from Scene:
Yes
No
Fuel Spill:
Yes
No
Hazmat Spill:
Yes
No
Is the owner of the vehicle different from the driver?
Yes
No
Provide owner's contact information
Name
Phone Number
Please enter a valid phone number.
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Other Vehicle(s) Involved Details
Please provide details of other vehicles/drivers involved in this incident.
Name
*
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vehicle Details
Year
Make
Model
Damage to other vehicle
Location of other vehicle
Insurance Details
Company Name
Policy Number
Is the owner of the vehicle different from the driver?
Yes
No
Provide owner's contact information
Name
Phone Number
Please enter a valid phone number.
Vehicle Towed from Scene?
Yes
No
Fuel Spill?
Yes
No
Hazmat Spill?
Yes
No
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Lawsuit Details
Use the sections below to provide details about the lawsuit.
State Where Filed
County Where Filed
Date of Service (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Please upload any lawsuit papers you'd like to include in this report
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Attestation
Name
*
This acts as a digital signature.
Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Signature
Should be Empty: