PRINT OUT THIS PAGE AND PLACE IT IN YOUR VEHICLE’S GLOVE COMPARTMENT. PUT ACCIDENT DESCRIPTION, DIAGRAM AND STATEMENTS MADE BY OTHER PARTIES ON THE REVERSE SIDE. GO TO THE HOSPITAL FOR AN EXAMINATION.
Ask to see the other driver’s:
Driving License
Owner’s Card
Insurance Card
OTHER DRIVER INFORMATION
Address:
Phone #:
Car Owner’s Phone #:
OTHER VEHICLE INFORMATION Make: Year: Model: Color: License Plate #: Vehicle I.D. # (VIN): Damage:
OTHER DRIVER’S INSURANCE COMPANY Name: Policy #: Effective Date: Name of Insured: Address: Insured Vehicle:
PASSENGER(S):
WITNESS(ES):
Name/Address/Phone #
ACCIDENT INFORMATION
Date:
Time:
Location:
Police Officer:
