DRIVER'S REPORT OF AUTOMOBILE ACCIDENT
Name _________________________ E-mail _____________________
Home address ______________________________________________
City _____________________ State _______ Zip ________________ Phone # ____________________
Employer's name ____________________________________________ Phone # ____________________
Employer's address _______________________________________________________________________
Are you married?_________ If yes, name of spouse ____________________________________________
Year ________ Make _______________ Model _____________ VIN ______________________________
Vehicle's plate # __________________ Color _______________ E-mail ____________________________
Driver ________________________________________ Driver's license # ____________________________
Driver's address _____________________________________________ Phone # ______________________
Date of birth________/________/________ Occupation __________________________________________
Was driver on errand for owner? ______ If yes, for what purpose?___________________________________
Did driver have permission to use vehicle? _______ Were all occupants wearing seat belts? ______________
Did you, or anyone with whom you reside, hold any automobile insurance policy on the date of this accident
other than the policy set forth above? Yes ____ No ____
Insurance company name: _________________________________________________________________
Policyholder's name: _________________________ Policyholder's relationship to you: __________________
Policy No. ____________________Claim No. (if any) ___________________________________________
Did you, or anyone with whom you reside, hold any umbrella or excess insurance policy on the date of this
accident? Yes ____ No ____
Insurance company name: _________________________________________________________________
Policyholder's name: ________________________ Policyholder's relationship to you: __________________
Policy No. ________________________________ Claim No. (if any) _______________________________
Were you in the course of your employment at the time of this accident? Yes ____ No ____
Employer name: __________________________________________________________________________
Address: __________________________________________________ Phone No. : ___________________
Insurance company name: ___________________________________
Policy No. ________________________________ Claim No. (if any) _______________________________
Name ________________________ Name _______________________ Name _______________________
Address ______________________ Address _____________________ Address _____________________
Phone Number ________________ Phone Number ________________ Phone Number ________________
Date of birth or age _____________ Date of birth or age ____________ Date of birth or age ____________
Seating Position (identify 2-8) _____ Seating Position (identify 2-8) ____ Seating Position (identify 2-8) ____
Name __________________________________________________________________________________
Address ______________________________________________ Claim # ___________________________
Name of insurance carrier ________________________________ Policy # ___________________________
Year ________ Make _______________ Model _____________ VIN ______________________________
Vehicle's plate # __________________ Color _______________
Driver ______________________________________ Driver's license # ____________________________
Driver's address _____________________________________________ Phone # ______________________
Date of loss _____________________________ Time ________ A.M. _____ P.M. ______
Street __________________________________ City __________________________State ___________
CAR
OWNER
YOUR
AUTO
AND
DRIVER
OTHER
INSURANCE
INFORMATION
PASSENGERS
OWNER
OF
OTHER
CAR
TIME AND
PLACE
AC-55 (4/16)
CLAIM NO.
2
5
8
7
63
4
1
2
5
8
7
63
4
1
2
5
8
7
63
4
1
