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Your Accident Fact KitWe hope you find our Accident Fact Kit helpful in the event of an accident. Please be sure to print multiplecopies and keep them in the glove compartment of your vehicle in the event of an accident. Don’t forget tokeep a pen with your kit. Keep the kit in your glove box, just in case you need it. The kit includes:Information Exchange (2 copies) Complete one of the forms and provide it to the other driver. Have the other driver complete the other form and return it to you. You will need this information when youreport your loss.Witness Information Separate the form and ask any witnesses to the accident to complete the form and return it to you. You willneed this information when you report your loss.Accident Details This form is to help you record accident details while the incident is still fresh in your memory. You may findit helpful to think about road and weather conditions, who was in your car, and other facts. You may needthis information to report your loss and refresh your recollection later.If you have an accident, remember these tips: Try to keep calm. Do whatever is necessary to protect your family members or passengers andyour property. Check for injuries, and get help if needed. Do not leave the scene of an accident. Do not admit responsibility at the accident scene or blame anyone else. Do not discuss the scope of your insurance coverage. Always notify law enforcement if there are injuries, death, or significant property damage related to theaccident. Cooperate with law enforcement officials. Record name, address, and phone numbers of any witnesses; a witness is someone that saw theaccident but was not involved in it. Note the date, time and location of the accident. Record details like cross streets, lane configurationsand weather conditions. Always report theft and vandalism issues to the police. Report all losses to us immediately.Call TimeSaver at 1-800-588-7400 to report losses.Drive Safely!PI-399

Your Accident Kit — page 2Information ExchangeComplete one copy of this form and give it to the other party. Give the other copy to the other party to completeand return to you. Seek information from police regarding injured parties.Accident Location Date & TimeAbout you:Driver’s NameStreet Address City & StateHome Phone Work Phone DOB Sex n M n FInjured? n Yes n No Nature of InjuryDriver’s License Number & State E-mailOwner’s Name (if other than driver)Street Address City & StateHome Phone Work Phone DOB Sex n M n FOwner’s License Number & State E-mailAbout your vehicle:Year Make ModelVehicle ID Number License & StateInsurance Company Name Policy # Telephone #Is Vehicle Drivable? n Yes n No Described Damage to Your VehicleAbout the passengers or pedestrians:NameDate ofBirthSex:M/FIf injured, indicatenature of injuryHome PhoneWork PhoneAddress

Your Accident Kit — page 3Information ExchangeComplete one copy of this form and give it to the other party. Give the other copy to the other party to completeand return to you. Seek information from police regarding injured parties.Accident Location Date & TimeAbout you:Driver’s NameStreet Address City & StateHome Phone Work Phone DOB Sex n M n FInjured? n Yes n No Nature of InjuryDriver’s License Number & State E-mailOwner’s Name (if other than driver)Street Address City & StateHome Phone Work Phone DOB Sex n M n FOwner’s License Number & State E-mailAbout your vehicle:Year Make ModelVehicle ID Number License & StateInsurance Company Name Policy # Telephone #Is Vehicle Drivable? n Yes n No Described Damage to Your VehicleAbout the passengers or pedestrians:NameDate ofBirthSex:M/FIf injured, indicatenature of injuryHome PhoneWork PhoneAddress

Your Accident Kit — page 4Witness InformationYou should give these cards to witnesses to fill out and return to you. Remember. . . a witness is someonethat saw the accident, but was not involved in it.Witness Information CardYour cooperation in providing this information will help us to be fair to everyone involved.Thank you.Accident LocationDate Time A.M./P.M.Did you see the accident happen?n Yesn NoDid you see anyone hurt?n Yesn NoWere you riding in one of the vehicles?n Yesn NoWere you a pedestrian involved in the accident?n Yesn NoYour NameStreet AddressCity & State Zip CodeTelephone: HomeWork E-mailWitness Information CardYour cooperation in providing this information will help us to be fair to everyone involved.Thank you.Accident LocationDate Time A.M./P.M.Did you see the accident happen?n Yesn NoDid you see anyone hurt?n Yesn NoWere you riding in one of the vehicles?n Yesn NoWere you a pedestrian involved in the accident?n Yesn NoYour NameStreet AddressCity & State Zip CodeTelephone: HomeWork E-mail

Your Accident Kit page 5Your Accident Kit — page 5Accident DetailsKeeping accurate records regarding the incident is important. You may wAccident Detailsfew minutes to complete this form while the details are still fresh. Thusedyourloss isorrecallingthe tofactslater.Keepingwhenaccuratereportingrecords regardingthe incidentimportant.You may wanttake a fewminutes tocomplete this form while the details are still fresh. This information can be used when reporting your loss orWhowasin myrecallingthe factslater. car at the time of the accident?Makesureinyouhaveinformationfor all passengers:Who wasmy carat thisthe timeof the accident?NameDate SexIf injured, indicateHome PhoneMake sure you have thisforall passengers:natureof injury------------------of information:BirthWork Phone Home PhoneNameDate ofM/F Sex:If injured, indicateBirthM/Fnature of injuryAddressAddressWork PhoneReport to authoritiesWas a police report made?YesReport numberNoIf yes, how?At scene At StationMailedName of police departmentWas a ticket issued?If yes, to whom?Report to authorities:n At SceneWas a police reportYes n Noyes, how?Conditionsatmade?then timeof Iftheaccidentn At Station n MailedReport number Name of police departmentRoad conditionsWeather conditionsWas a ticket issued? n Yes n No If yes, to whom?Damagetoat mycar of the accident:Conditionsthe timeLicenseplate# and state of the carI Weatherwas drivingRoad conditionsconditionsDamage tomy car:VehicleMileageIs the vehicle drivable?YesNoLicense plate # and state of the car I was drivingArea and extent of damage to my vehicle:Vehicle mileage Is the vehicle drivable? n Yes n NoArea and extent of damage to my vehicle:Use the space below to diagram what happenedUse the space below to diagram what happened:Useto toUsearrowarrowindicateNorthindicate North

Vehicle mileage _ Is the vehicle drivable? n Yes n No Area and extent of damage to my vehicle: Use the space below to diagram what happened: Your Accident Kit — page 5 Your Accident Kit page 5 Accident Details Keeping accurate records regarding the incident is important. You may want to take aFile Size: 214KBPage Count: 5Explore furtherAccident Investigation Form Samplewww.mocounties.comSample letter for Car accident reportwww.careerride.comAuto Accident Checklistwww.insureuonline.orgAccident and Incident Forms for Driver Crash Reportingwww.jjkeller.comHow to Determine Who Is at Fault in a Car Accident: 11 Stepswww.wikihow.comRecommended to you b