Report ClaimFernando2022-09-27T18:58:18-04:00 ACCIDENT REPORT Insured Policy Number ACCIDENT INFORMATION Date of Accident Time Location of Accident Responding Police Department Police Report Number Accident Facts (describe how accident occurred) INSURED VEHICLE INFORMATION INSURED VEHICLE - (vehicle #/owner's name/year/make/model/VIN #) INSURED DRIVER'S INFORMATION - (name, D/L #, address, phone) DESCRIPTION OF DAMAGE TO INSURED VEHICLE OTHER VEHICLE INFORMATION OTHER VEHICLE - (year/make/model/tag #/insurance co name/policy #) OTHER OWNER/DRIVER'S INFORMATION - (name, D/L #, address, phone) DESCRIPTION OF DAMAGE TO ADVERSE VEHICLE INJURED PARTIES First Name Last Name ADDRESS INJURIES INVOLVEMENT WITNESSES OR PASSENGERS First Name Last Name ADDRESS INVOLVEMENT ADDITIONAL INFORMATION REMARKS NAME OF PERSON REPORTING ACCIDENT Email Applicable in Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
