Western Vehicle
ACCIDENT REPORTING FORM
To be completed at the scene. (Important: Do not admit liability or discuss any settlement.)
If there are personal injuries or severe damage to the vehicle, call 911.
If vehicle is drivable and if it’s safe to do so, pull to the side of road away from traffic.
Put out beacons or flares if available.
If you have a camera, record the damages at the scene.
Complete a detailed description of the accident and record all relevant information on this form.
File this report to the Western Corporate Insurance office within 24 hours.
File a report with the London Police Reporting Centre, 1001 Brydges Street London, if necessary.
Date of Accident:_______________________________ Time of Accident: ________________
Location of Accident: ___________________________________________________________
Western Vehicle Involved: ______________________________________________________
Make/Model/Year of Western Vehicle: _____________________________________________
License Plate No.:______________________ Your Speed at Time of Accident: ________ kms
Employee Name: ______________________________________________________________
Department: _________________________________ Phone No.:_______________________
License No.:_________________________________
Weather Conditions: _______________________ Road Conditions: _____________________
Details of any Injuries: __________________________________________________________
____________________________________________________________________________
Names/Addresses of any Injured Persons:
____________________________________ _____________________________________
____________________________________ _____________________________________
____________________________________ _____________________________________
Description of What Occurred: (please provide as much detail as possible)
____________________________________________________________________________________
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____________________________________________________________________________________
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Western Vehicle ACCIDENT REPORTING FORM
Witness #1: Name, Address, Phone No.
________________________________________
________________________________________
________________________________________
________________________________________
License Plate No.: ________________________
Witness #2: Name, Address, Phone No.
________________________________________
________________________________________
________________________________________
________________________________________
License Plate No.: ________________________
Other Vehicle #1 or Property Involved:
Driver’s Name: ____________________________________ Phone No.: __________________
Driver’s License No.: _________________________ Owner’s Name: _____________________
Driver’s & Owner’s Address: _____________________________________________________
____________________________________________________________________________
____________________________________________________________________________
License Plate No.: ________________________________
Make/Model/Year of Vehicle: _____________________________________________________
Insurance Company: _______________________________ Policy No.: __________________
Other Vehicle #2 or Property Involved:
Driver’s Name: ____________________________________ Phone No.: __________________
Driver’s License No.: ________________________ Owner’s Name: ______________________
Driver’s & Owner’s Address: _____________________________________________________
____________________________________________________________________________
____________________________________________________________________________
License Plate No.: ________________________________
Make/Model/Year of Vehicle: _____________________________________________________
Insurance Company: ________________________________ Policy No.: _________________
Western Accident Report No.
Collision Report Incident No.
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