5. PERSONAL INJURIES Name of injured person _____________________________________________________________________________
Address _____________________________________________________________________________________________________________________
Age ______________ Occupation ____________________________________________ Social Security No. __________________________________
Injuries ______________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Name and address of treating Doctor _________________________________________________________________________________________
Where was injured person taken? _________________________________________________________________________________________________
Where was injured person at time of accident? ___________________________________________________ Seat Belts In Use? Yes No
What statement was made by injured person? _______________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Do you anticipate claim being made against you? _____________________________________________________________________________________
6. OTHER CAR OR PROPERTY INVOLVED (NOT YOUR CAR)
Name and address of owner of damaged auto or other property damaged. _________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Home Phone ___________________________ Business Phone __________________________ Social Security No. _____________________________
Name of other party's insurance carrier ________________________________________________ Policy No. __________________________________
Make of automobile ___________________________ Year ___________ Body Type ____________________ Model __________________________
Describe damage to auto or other property __________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
License Plate No. and State _____________________________ Estimated Repair Cost $ ____________________________________________________
Name of Driver of other car ________________________________________ Address _____________________________________________________
Drivers License No. ______________________________________ Social Security No. _________________________________ Age of Driver _______
Occupants of other car ____________________________________________ Address _____________________________________________________
_______________________________________________________________ Address _____________________________________________________
Where can investigator see other car? ______________________________________________________________________________________________
What was said between you and other driver ________________________________________________________________________________________
IMPORTANT: Is claim being made against you? _______________________________ Are you making claim against the other party? _________
7. DAMAGE TO POLICYHOLDER'S AUTOMOBILE:
State cause of damage or loss if other than accident ___________________________________________________________________________________
_______________________________________________________________________________ Date of loss___________________________________
Describe parts, nature and extent of loss ____________________________________________________________________________________________
________________________________________________________________________ Estimated cost of repairs $ _____________________________
If theft, were police notified? ________________ When _______________________ Officer's name and number ________________________________
Give make, size and mileage of tires stolen or damaged ________________________________________________________________________________
Age of convertible top ________________________________________ Purchase date and warranty of battery __________________________________
8. WITNESSES / THIS IS IMPORTANT The names and addresses of all witnesses, bystanders or people in the immediate vicinity who may have
seen the accident or heard any statement made, should be listed.
Name _________________________________________ Telephone No. ________________________ Social Security No. _______________________
Address _______________________________________________________City____________________________________State___________________
Name __________________________________________ Telephone No. ________________________ Social Security No. _______________________
Address _______________________________________________________City____________________________________State___________________
For your protection, Minnesota law requires the following to appear on this form:
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
9. CERTIFICATE I certify that the foregoing is correct to the best of my knowledge and belief.
Policyholder’s Signature _____________________________________________
Date of this report _______________________________________ Driver’s Signature
(If other than Policyholder) ___________________________________________
