Fillable Driver Questionnaire To complete this form electronically Or (Plymouth Rock Assurance)

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Driver Questionnaire To complete this form electronically Or (Plymouth Rock Assurance)

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  • 71 check-boxes
  • 128 other fields

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File type: PDF

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Driver Questionnaire
To complete this form
electronically
:
1 Save this writable PDF to your computer, then open it using
Adobe’s Acrobat Reader.
Or
2 Complete the form by typing in each field and/or checking
the appropriate buttons.
Tip: you can tab from field to field.
3 When finished, save and print the form. Then mail the form to
Plymouth Rock’s Claims Department at the address provided
at the end of the form.
Complete this form to the best of your knowledge and belief. DO NOT GUESS at any answers. If you don’t know the answer to a
question, leave that field blank. Please call your Claim Representative if you need help.
CLAIM NUMBER
(12-digit
b )
DRIVER’S PERSONAL INFORMATION
Driver’s
First
Name:
Driver’s
Last
Name:
Driver’s License Number:
Date of Birth:
/ /
Street Address:
City: State: Zip Code:
Home Phone: ( ) – Work Phone: ( ) – Cell Phone: ( ) –
INFORMATION ABOUT THE VEHICLE YOU WERE DRIVING (VEHICLE 1
)
Year: Make: Model:
License Plate Number:
Are you the owner of this vehicle?
¡
Yes
¡
No
IF NO, please provide owner’s name and your purpose for using the vehicle.
Owner’s
First
Name:
Owner’s
Last
Name:
Purpose of Your Use of Vehicle:
Number of Passengers:
IF ANY, please list the first and last name of each passenger below.
Passenger 1:
Passenger 2:
Passenger 3:
Passenger 4:
ADDITIONAL VEHICLES INVOVLED IN THE ACCIDENT
(If needed, provide additional information on a separate page.)
Additional
Vehicle
2
Year:
Make:
Model:
License Plate Number:
Driver’s First & Last Name:
Driver’s License Number:
Insurance Company:
Policy Number:
Number of Passengers:
Passenger 1:
Passenger 2:
Passenger 3:
Passenger 4:
Additional
Vehicle
3
Year:
Make:
Model:
License Plate Number:
Driver’s First & Last Name:
Driver’s License Number:
Insurance Company:
Policy Number:
form continues
Driver Questionnaire (continued)
Additional
Vehicle
3
Number of Passengers:
IF ANY, please list the first and last name of each passenger below.
Passenger 1:
Passenger 2:
Passenger 3:
Passenger 4:
DETAILS ABOUT THE ACCIDENT
Date of Accident:
/ /
Time of Accident:
:
¡
am
¡
pm
Location of Accident:
Your Vehicle (1)
Travel Direction:
(North, South, East, or West)
Speed:
(mph)
Additional Vehicle 2
Travel Direction:
(North, South, East, or West)
Speed:
(mph)
Additional Vehicle 3
Travel Direction:
(North, South, East, or West)
Speed:
(mph)
Describe the Accident’s sequence of events
(If needed, provide additional information on a separate page.)
What happened first?
What happened second?
What happened third?
What happened fourth?
As a result of the accident,
were you injured?
¡
Yes
¡
No
IF YES, what were your injuries?
was anyone else injured?
¡
Yes
¡
No
IF YES, please provide names and associated injuries in the spaces below.
Person 1
First & Last Name: Injuries:
Person 2
First & Last Name: Injuries:
Person 3
First & Last Name: Injuries:
(If needed, please provide additional names and injuries on a separate page.)
Initial I mpact
(Please click on all points of impact on each vehicle )
Vehicle 1
(Your Vehicle)
Vehicle 2
Vehicle 3
Front
Rear
Front
Rear
Front
Rear
Describe the Damage to each Vehicle
(If needed, provide additional information on a separate page.)
Vehicle 1
Damage:
Vehicle 2
Damage:
Vehicle 3
Damage:
form continues
Driver Questionnaire (continued)
Did police come to the accident scene?
¡
Yes
¡
No
IF YES, which police department?
Were any citations issued?
¡
Yes
¡
No
IF YES, to whom?
(First & Last Name)
Witnesses to the Accident
(If needed, please provide additional names and injuries on a separate page.)
Were there any witnesses that were not passengers in any vehicles involved?
¡
Yes
¡
No
IF ANY, please provide information below.
Witness 1
First & Last Name: Best Contact Phone: ( ) –
Street Address:
City: State: Zip Code:
Witness 2
First & Last Name:
Best Contact Phone: ( ) –
Street Address:
City: State: Zip Code:
Witness 3
First & Last Name:
Best Contact Phone: ( ) –
Street Address:
City: State: Zip Code:
Witness 4
First & Last Name:
Best Contact Phone: ( ) –
Street Address:
City: State: Zip Code:
Did anyone have a traffic control (i.e., stop sign, traffic light, etc.)? Yes No
Driver Questionnaire (continued)
Please use the following diagram to give a visual representation of how the accident occurred.
Indicate the vehicles involved
and direction of travel using
the following symbols:
= Direction
1
= Your Vehicle
2
= Vehicle 2
3
= Vehicle 3
= Pedestrian
✘
/ /
Driver’s Signature
Date
Claims department
Plymouth Rock Assurance Corporation, PO Box 902 Lincroft, NJ 07738
Fax # - 732-978-7199
Thank you.
All Rights Reserved ©2012 Rev_02_12
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Driver Questionnaire To complete this form electronically Or (Plymouth Rock Assurance)

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Completed 24 February 2022

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