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This is a helpful form to have printed and in the car in the event of an accident, to record all of the necessary details of what happened, contact and insurance information, and other important information.
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Insurance Company
FARMERS
]AR]TIERSAccidentBeIort
Ia lmelsPol icyholders
Gal l :1-800-435-fr64
or log ontoww.farmerc.Gomto lenolt a loss 01checl on a claim.
@
FARMERSw
Phone #
Policy #
Expiration date
Registration information on other vehicle
Name and address of the reqistered owner
Address
VIN #
Expiration Date
6. Occupants of other vehicle
A. Name
Address
Phone #
Age
Age
O Female O Male
B. Name
O Female O Male
Address
Fill out this report as completely as possible.
1.
2.
Time Date
Police called? O Yes O No
3. Name of
Address
other driver
Phone #
Drive/s License #
License Plate #
4. Policereporttaken? OYes O No
Report #
Witness information
A. Name
Address
Phone #
Name
Address
Phone #
7. # of Injuries?
Your own
Your passengers
Pedestrians
Other driver
Their passengers
8. Location ofaccident
9. Direction of travel
OtherVehicle
YourVehicle
l0.Speed oftravel
Other vehicle
Your vehicle
11.Area of damage
Other vehicle
Your vehicle
Phone #
Make sure you complete the diagram on the back
Description of the accident.Diagram of
Accident SceneUsing these symbols complete the diagram showingpositions of all vehicles, your position, stop lights, stopsigns and pedestrians.
First Car
Second Car
Third Car
X vorrposition
f ,"d"r.r,un
Q StopSign
ff s.o t-isr''.'W witn"r,
EEtI
w{ Fr
Name of EastMest Street:
Name of North/South Street:
