AFFIDAVIT OF INSURANCE COMPANY,
AGENT FOR INSURANCE COMPANY, AGENT, LAWYER
I swear and subscribe that I
am an individual involved in an accident for which a Police Report was filed.
am an authorized agent for an individual(s) who was/were a party to the accident.
am an authorized agent from an insurance company representing an insured party to an accident.
am an attorney representing a client who was a party to the accident.
The following box must be checked:
I understand that only certain individuals are entitled to a copy of this Accident Report.
All information in the box below is required:
Name of Individual, Insurance Company, Agent for Insurance Company, Agent, Attorney:
Insurance Company NAIC Number: Attorney ID No.
Address:
Telephone Number:
Name of Individual involved in the accident or Client, Insured:
Address of Individual involved in the accident or Client, Insured:
COPIES OF: FEE NO. OF
COPIES
APPLICANT
FEE
Incident Report $25.00 $
Photographs $ per copy $
Video – *Subpoena Required $35.00 $
FEE WAIVED FOR DREXEL AFFILIATES – PROPER ID REQUIRED
FEES ARE NON-REFUNDABLE
Total $
Complete this form in full and mail a copy with the appropriate fee to:
Drexel University
Attention: Thomas Degnan
3201 Arch Street, Suite 350
Philadelphia, PA 19104
TO EXPEDITE SERVICE, PLEASE SEND A SELF-ADDRESSED, STAMPED ENVELOP.
Make Checks or Money Orders payable to “Drexel University Department of Public Safety”
Under penalties of law or ordinance, and 18 PA C.S. Sec. 4120, and 18 PA C.S. Sec. 4904, I declare that the
information on this form and accompanying documentation is accurate and complete.
Signature: Date:
