Driver’s Accident Report Form

IN THE EVENT OF AN ACCIDENT

NONPROFIT / INSURED
Driver – Complete all items to the best of your ability, sign and date page 3, and immediately give it to your supervisor.
Supervisor – Fax this Driver’s Accident Report form to your insurance broker immediately.
BROKER – Refer to our website for instructions on claim reporting.

If a claim needs to be reported after business hours or on the weekend, call (866) 718-1947.
This number is reserved for true claims emergencies after business hours and weekends.

Driver/Vehicle Information
Name of Driver (first and last) Driver’s Age Driver License No. State

Driver’s Address – Street City State Zip Telephone No.

( )
Name of Nonprofit / Employer ANI/NIAC Policy Number

Nonprofit/Employer Contact Name Contact Email Address

Nonprofit / Employer Address – Street City State Zip Telephone No.

( )
Make of Nonprofit’s Vehicle Body Type Year License Plate # V.I.N. (last four digits)

Damage to Nonprofit’s Vehicle:

Accident Information
Date of Accident Day of Week (circle one) Time of Accident Location - Street or Highway & City
Mon Tue Wed Thurs Fri Sat Sun AM / PM
On what street were you driving? Direction (circle one) Speed (approximate)
N S E W
On what street was other vehicle driving? Direction (circle one) Speed (approximate)
N S E W
Police Report? If yes, name of reporting officer Agency Citation/Report #
Yes No
Witness #1 Name (first and last) Telephone No. Email Address
( )
Witness #2 Name (first and last) Telephone No. Email Address
( )
Description of Accident (include weather and road conditions):

(Use the back of this sheet if additional space is needed; please use the diagrams on page 3 to draw the accident)

Serving …

www.insurancefornonprofits.org
 Passenger(s) in Your Vehicle (attached additional pages if needed)
Name (first and last) Telephone No. Email Address Age Injuries?
( ) Yes No
Name Telephone No. Email Address Age Injuries?
( ) Yes No
Name Telephone No. Email Address Age Injuries?
( ) Yes No
Ambulance called to scene? Name of doctor or hospital
Yes No

Other Vehicle Involved

Name of Driver (first and last) Driver License No. State

Address - Street City/State/Zip Telephone No. Email Address

( )
Name of Vehicle Owner (if different than above) Telephone No. Email Address
( )
Name of Insurance Company Policy # Telephone No.
( )
Year/Make of Vehicle Body Type License Plate No. State

Damage to Vehicle:

Passenger’s Name (first and last) Telephone No. Email Address Age Injuries?
( ) Yes No
Passenger’s Name (first and last) Telephone No. Email Address Age Injuries?
( ) Yes No

Other Vehicle Involved (if any)

Name of Driver (first and last) Driver License No. State

Address - Street City/State/Zip Telephone No. Email Address

( )
Name of Vehicle Owner (if different than above) Telephone No. Email Address
( )
Name of Insurance Company Policy # Telephone No.
( )
Year/Make of Vehicle Body Type License Plate No. State

Damage to Vehicle:

Passenger’s Name (first and last) Telephone No. Email Address Age Injuries?
( ) Yes No
Passenger’s Name (first and last) Telephone No. Email Address Age Injuries?
( ) Yes No

LC-DAR 04_12 Pg 2 of 3
On the diagrams below, please draw the accident. Legend: N
(Be sure to include any stop signs or traffic signals.) V 1 X Your Vehicle Å
V 2 X Other Vehicle WÃÄE
V 3 X Other Vehicle (if any) Æ
S

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On the overhead diagrams below, please indicate the location of damage to your vehicle, if any.

back ------------ VAN ------------ front back ------------ AUTO ----------- front

SIGNATURE OF DRIVER DATE

LC-DAR 04_12 Pg 3 of 3