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ACCIDENT INFORMATION FORM

Print and Keep This In Your Glove Box



This document contains important information and should be completed in case of an accident


Remain at the scene of the accident and stay calm.

Notify the police.

Exchange information with other driver.

Other Driver:

Name: ___________________________________________

Address: _________________________________________

Telephone Number: _________________________________

Driver's License Number: _____________________________

Insurance Company: _________________________________

Policy Number: ______________________________________

Year, Make, Model, Color of Vehicle: _____________________

License Tag Number: __________________________________

Owner (If not the driver):

Name: ___________________________________________

Address: _________________________________________

Telephone Number: _________________________________

Driver's License Number: _________________________________

Insurance Company: _________________________________

Policy Number: _________________________________


Witness 1:

Name: ___________________________________________

Address: _________________________________________

Telephone Number: _________________________________

Witness 2:

Name: ___________________________________________

Address: _________________________________________

Telephone Number: _________________________________

Passenger:

Name: ___________________________________________

Address: _________________________________________

Telephone Number: _________________________________

Statement by Other Driver:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

Police:

Police Department: __________________________________

Investigating Officer: _________________________________

Badge Number: _____________________________________

Report Number: _____________________________________

Accident Information:

Date of Accident: ____________________________________

Time of Accident: ____________________________________

Weather Condition: ___________________________________

Accident Diagram:



Show the following:

Street you were on: ___________________________________

Your direction of travel: _________________________________

Street other driver was on: _______________________________

Other driver's direction of travel: ___________________________

 

LAW OFFICES
OF
HAROLD SEMANOFF

2617 Huntingdon Pike
Huntingdon Valley, PA 19006

Phone:215-887-0200

hsemanoff@sogtlaw.com

 

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IN THE HEART OF THE SUBURBS