Accident report

Friendly declaration of accident

ALL FIELDS MARKED WITH * ARE REQUIRED
4. PROPERTY DAMAGE

VEHICLE A (OWN)

6. INSURED (See Insurance Policy)
7. VEHICLE
8. INSURANCE
9. DRIVER (see driver's license)
12. CIRCUMSTANCES. INDICATE "YES" IN EACH BOX AS APPROPRIATE

VEHICLE B (OPPOSITE)

6. INSURED (See Insurance Policy)
7. VEHICLE
8. INSURANCE
9. DRIVER (see driver's license)
12. CIRCUMSTANCES. INDICATE "YES" IN EACH BOX AS APPROPRIATE

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