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
List parts of your car damaged ______________________________________________________________
Have you obtained an estimate of damages? __________ If yes, amount of estimate $ __________________
Name and address of body shop preparing estimate _____________________________________________
_______________________________________________________________________________________
Was anyone injured? ___________
Name ___________________________________________ Age _______ E-mail ____________________
Address ____________________________________________________ Phone # __________________
Nature of injuries _________________________________________________________________________
Name ___________________________________________ Age _______ E-mail ____________________
Address ____________________________________________________ Phone # __________________
Nature of injuries _________________________________________________________________________
Were there any witnesses to the accident other than occupants of your car? ___________________________
Name ___________________________________________ Age _______ E-mail ____________________
Address ____________________________________________________ Phone # __________________
Name ___________________________________________ Age _______ E-mail ____________________
Address ____________________________________________________ Phone # __________________
Name ___________________________________________ Age _______ E-mail ____________________
Address ____________________________________________________ Phone # __________
Was report made to police? _____________ Case # _____________________________________
Name of police department _________________________________________________________________
Was anyone charged? __________ Who? _________________________ Charges? ___________________
Was there any evidence of drinking? ______ If yes, who? _______________________________________
Was either driver talking on a cellular phone? _________ If yes, who? _______________________________
Traffic control (stop sign, signal lights, etc.) _____________________________________________________
Weather conditions at time of accident ________________________________________________________
Were your headlights on? _________ Road conditions ___________________________________________
Direction your car was going ______________________ Side of street ____________ Speed ____________
Direction of other car ____________________________ Side of street ____________ Speed ____________
When did you notice the other car involved? ____________________________________________________
Did you give warning signal? ___________ What kind? ___________________________________________
Did other car give warning? ____________ What kind? ___________________________________________
Give description of how loss occurred _________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
SHOW HOW ACCIDENT OCCURRED BY USING ONE OF THESE DIAGRAMS (Next Page)
DAMAGE
TO YOUR
CAR
PERSONS
INJURED
WITNESSES
DESCRIPTION
OF ACCIDENT
IMPORTANT
Please ll in diagram show-
ing position of automobile and
injured person (or other vehicle
with which insured's automobile
collided) with direction in which
both were proceeding.
Your Car
Other Car
Trailer
Motorcycle
Pedestrian
Teams
Direction
Indicate Points
of Compass
N E S W
NOTICE REQUIRED BY INSURANCE REGULATORS
Any entity engaged in the business of auto body repairs must be licensed. Insurers are prohibited from negotiating, adjust-
ing or settling an automobile damage claim with an unlicensed facility.
Any person who knowingly les a statement of claim containing any false or misleading information is subject to criminal
and civil penalties.
First Name
DATE
OF REPORT _____________________________________________
Last Name
By checking this box and providing my name below, I hereby accept and adopt as my own the information
provided on this form, and I attest to the truth of its contents.