DRIVER'S REPORT OF ACCIDENT
IN CASE OF AN ACCIDENT DO THE FOLLOWING:

1. SEE IF ANYONE IS HURT.

2. CALL FOR HELP IF NEEDED.

3. CALL POLICE TO REPORT ACCIDENT.

4. DO NOT ADMIT FAULT.

5. CALL YOUR INSURANCE AGENT AS SOON AS POSSIBLE.

6. EXCHANGE INFORMATION WITH OTHER PEOPLE IN THE ACCIDENT.

7. IF A CAMERA IS READILY AVAILABLE, TAKE PICTURES OF ACCIDENT SCENE, INCLUDING ANY PERSONS AND DAMAGED
   
ITEMS INVOLVED.

8. COMPLETE AS MANY DETAILS AS POSSIBLE ON THIS FORM AND MAIL A COPY TO YOUR INSURANCE AGENT.

ENTER THE INFORMATION BELOW FOR QUICK REFERENCE

NAMED INSURED ____________________________________________________
POLICY NUMBER ____________________________________________________
INSURANCE AGENT __________________________________________________


FILL OUT THIS FORM AT ACCIDENT SCENE
DATE ___/___ /___ TIME ____________

YOUR VEHICLE:

YEAR ______ MAKE_________ PLATE# ___________
SERIAL NUMBER ______________________________
DRIVER NAME ________________________________
ADDRESS ____________________________________
LICENSE NUMBER _____________________________
PHONE# HOME_____________ WORK ______________

OTHER CAR:

YEAR ______ MAKE_________ PLATE# ___________
SERIAL NUMBER ______________________________
DRIVER NAME ________________________________
ADDRESS ____________________________________
LICENSE NUMBER _____________________________
PHONE# HOME_____________ WORK ______________
INSURANCE COMPANY __________________________


STREET NAME(S) ON WHICH ACCIDENT OCCURRED
_________________________________________________________
NEAREST INTERSECTING ROAD _________________________________________________________
POLICE CONTACTED _________________________________________________________
YOUR CAR TOWED TO _________________________________________________________
OTHER CAR TOWED TO _________________________________________________________
YOUR CAR DAMAGED AREA _________________________________________________________
OTHER CAR DAMAGED AREA _________________________________________________________
GIVE A BRIEF DESCRIPTION OF THE ACCIDENT
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

NAME, ADDRESS, PHONE NUMBER OF ANY WITNESS
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

NAME, ADDRESS, PHONE NUMBER OF ANY INJURED
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

WAS ANY OTHER PROPERTY DAMAGED INCLUDING SIGNS,
GUARD RAILS, ETC. PLEASE LIST:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

PLEASE USE THE BACK OF THIS FORM FOR ANY OTHER INFORMATION, NOTES,
OR A DIAGRAM OF THE ACCIDENT OR LISTING OTHER CARS INVOLVED.ANY PERSONS AND DAMAGED ITEMS INVOLVED.