ACCIDENT AFFIDAVIT
CLAIM #:

(ALL QUESTION MUST BE ANSWERED.)

Owner Information

Car owner's name:
Address:
Phone:

Name of Spouse    Married Single

Driver Information

Driver's Name:
Address
Phone

Place of Employment:
Employer Phone:

Accident Information

Date of Accident:
Time:
    AM PM

Location of Accident:

Your Vehicle Information

Make: Model: Vehicle Year: License Plate#

What was the car being used for at the time of the accident

Was your vehicle repaired: Yes No                       Cost of Repairs? When

Where

How many people were in your car?      In other car?

Name and address of occupants of your vehicle who where injured (including yourself)

Medical Information

Was medical treatment required?: Yes No
if Yes, Doctors name:
Hospital

Other Parties Driver Information

Name and address of driver of other vehicle?

Name and Address of Occupants of other vehicle who were injured (including driver)?

Other Parties Vehicle Information

Year Make of other Vehicle: License #

Was accident reported to Police Department? Yes No
if Yes, Which Department:

Court Information

Which driver received the ticket? What was the charge:

What plea was entered? Guilty Not Guilty
What was the court decision:

Who witnessed the accident? Give name and address:

Insurance Information

Name of your insurance company:

Name of company insuring other parties:

Accident Description

How did the accident happen? Give full account, starting speed and direction of each car:

Did you take any photographs or statements from anyone? Yes No
Did you give anyone a statement:
Yes No

Date of last automobile accident prior to this one.

Please be sure all information is correct before you continue.

*Owner Information*
Car owner's name:		Address:	Phone:
Name of Spouse	Married Single
*Driver Information*
Driver's Name:		Address	Phone
Place of Employment:		Employer Phone:
*Accident Information*
Date of Accident:		Time:	AM PM
Location of Accident:
*Your Vehicle Information*
Make:	Model:	Vehicle Year:	License Plate#
What was the car being used for at the time of the accident
Was your vehicle repaired:	Yes No Cost of Repairs?	When	Where
How many people were in your car?		In other car?
Name and address of occupants of your vehicle who where injured (including yourself)
*Medical Information*
Was medical treatment required?:	Yes No	if Yes, Doctors name:	Hospital
*Other Parties Driver Information*
Name and address of driver of other vehicle?
Name and Address of Occupants of other vehicle who were injured (including driver)?
*Other Parties Vehicle Information*
Year Make of other Vehicle:		License #
Was accident reported to Police Department?	Yes No	if Yes, Which Department:
*Court Information*
Which driver received the ticket?		What was the charge:
What plea was entered?	Guilty Not Guilty	What was the court decision:
Who witnessed the accident? Give name and address:
*Insurance Information*
Name of your insurance company:
Name of company insuring other parties:
*Accident Description*
How did the accident happen? Give full account, starting speed and direction of each car:
Did you take any photographs or statements from anyone?	Yes No	Did you give anyone a statement:	Yes No
Date of last automobile accident prior to this one.
Please be sure all information is correct before you continue.