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Disclaimer

You can download this form by clicking here. Please print and leave in your glove compartment for future use.

ACCIDENT INFORMATION LIST

DO NOT admit liability and do not discuss your accident with anybody except your own insurance agent, the police or your attorney.

DO write down names, addresses and license numbers of persons involved and names and addresses of witnesses.

DO notify the police immediately.

DO promptly report any accident to your insurance agent.

OTHER VEHICLE:
 

Driver's Name_____________________________________________________________
Address _________________________________________________________________
City & State ______________________________________________________________
Phone___________________________________________________________________
Driver's License # __________________________________________________________
Vehicle Description ________________________________________________________
License Plate # and State___________________________________________________
Owner of Vehicle __________________________________________________________
Address _________________________________________________________________
City & State ______________________________________________________________
Phone ___________________________________________________________________
Insurance Co. _____________________________________________________________
Policy No. ________________________________________________________________
Damage__________________________________________________________________

VEHICLE YOU WERE IN:

Year & Make______________________________________________________________
Driver____________________________________________________________________
Address__________________________________________________________________
City & State_______________________________________________________________
Phone____________________________________________________________________
Owner____________________________________________________________________
Address__________________________________________________________________
City & State_______________________________________________________________
Phone____________________________________________________________________
Insurance Co.______________________________________________________________
Policy No._________________________________________________________________
Damage__________________________________________________________________

WITNESS:

Name____________________________________________________________________
Address__________________________________________________________________
City & State______________________________________________________________
Phone___________________________________________________________________ Name___________________________________________________________________
Address_________________________________________________________________
City & State______________________________________________________________
Phone___________________________________________________________________
 

ABOUT THE ACCIDENT:

Time & Date_______________________________________________________________
Location__________________________________________________________________
Describe What Occurred ____________________________________________________

_________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Ambulance Called?_______________________________________________________
Were Police Present?_____________________________________________________
What Department?________________________________________________________
Who Received Ticket? ____________________________________________________

 
IN THE AREA BELOW, DRAW AS BEST YOU CAN, A DIAGRAM OF THE LOCATION OF THE ACCIDENT INCLUDING INTERSECTING STREETS AND THE DIRECTION OF ALL VEHICLES INVOLVED:

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This website is designed to provide general information to the public and is not intended to offer legal advice about your specific situation.  McNeely Law Office of Shelbyville, Indiana, does not create an Attorney-Client Relationship by offering this information and your review of this information does not create an Attorney-Client Relationship. You should consult an Attorney At Law if you have a legal matter requiring attentionContact Us for more information.

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