AUTOMOBILE CLAIM FORM

What to do in Case of an Accident:

	STOP!!!.  Remain, Courteous, Calm, and be very Helpful.  Help Injured persons get medical assistance.
	Get the names of Owners and Drivers involved, Name of their Insurance Company,  Driver's License Numbers, Registration Numbers of cars involved, Names and Addresses of all Occupants.
	If Witnesses, get Names, Addresses and Phone Numbers.
	Remember locations of cars or pedestrians involved in the accident, both prior to its occurrence and afterward, so that you will be able to draw a diagram.
	Express NO opinion as to whom was at fault.  Give NO information except as required by the authorities.  Sign NO statement for anyone except required by authorities.
	When an accident occures Notify A.J.Bonocore Agency via fax, E-Mail, or Phone. Fill out report below and submit.
	Ascertain from local police what accident reports are required of you.
	Your intrest will be sreved best if you are courteous and Engage in NO Controversy at the Scene of the accident but leave the entire handling of the claim to the insurance company.

   DRIVER #1--YOUR VEHICLE INFORMATION

Your Name as it appears on your Drivers License:

Street Address: City:

State AK AL AR AZ CA CO CT DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip:

Home Phone: Work Phone: Fax #

E-Mail Address

Drivers License # License Plate #

Year of Car: Make of Vehicle:

Model:   VIN#

ACCIDENT:

Date: Time: AM PM

Location of Accident:

Vehicle Speed: Direction: North East South West

CONDITIONS:

Pavement: Dry   Wet   Ice   Snow        Weather  

Visibility:    Traffic Control   Lights   Signs   None

Police Investigation: Yes No      Report #:

Police: City County State Highway Other Police Officers Name:  

 Police Officers Badge #:    Summons Issued: Yes No                

To Whom?

DRIVER #2--OTHER VEHICLE INFORMATION

Other Drivers Name as it appears on their Drivers License:

Street Address: City:

State: AK AC AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Zip:

Home Phone:  Work Phone : Fax# :

E-Mail Address:

Drivers License #  License Plate #

Year of Car:   Make of Vehicle:

Model:  VIN#  

OTHER PEOPLE INVOLVED IN ACCIDENT

Name:  Address:

City:  State: AK AC AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip:

Phone #  In : Your Vehicle   Other Vehicle   Pedestrian

Injured? Yes No  

Describe Injury:

COURTESY INFORMATION

Comments: (Please describe what you saw)