| 1. |
Date of the
Accident: _______________________Time:
____________ a.m./p.m. |
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| 2. |
Location of the
accident:
_______________________________________________________________ |
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| 3. |
Name and driver’s
license number(s) of the other driver(s): |
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____________________________________________________________________________________ |
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____________________________________________________________________________________ |
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| 4. |
Year, Make, Model,
Color, and License Plate No. of each vehicle: |
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____________________________________________________________________________________ |
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____________________________________________________________________________________ |
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____________________________________________________________________________________ |
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____________________________________________________________________________________ |
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| 5. |
Insurance Company
& Policy No. for each vehicle: |
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____________________________________________________________________________________ |
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____________________________________________________________________________________ |
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____________________________________________________________________________________ |
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| 6. |
Witness No. 1, Name,
Address, & Phone No. |
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____________________________________________________________________________________ |
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____________________________________________________________________________________ |
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Witness No. 1, Name,
Address, & Phone No. |
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____________________________________________________________________________________ |
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____________________________________________________________________________________ |
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| 7. |
Was anyone injured?
List any places where anyone was injured, bruised,
bleeding, cut, or sore: |
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____________________________________________________________________________________ |