Help

AFFIDAVIT OF ACCIDENT (All Questions Must be Answered)

Name of Owner of Car:    _        

Telephone No. _        

Owner Address:         _        

Driver Name:         _        

Phone _        

Age _        

Driver Address:         _        

Place of Employment:     _        

Work Phone:  _        

Married or Single? _        

(if married, spouse name) _        

Date and Time of Accident:  _        

Location: _        

Your Car Make:

Year

Model :

License No:

If you are not the driver of the vehicle at the time of loss, what is their relationship to you?[pic 1][pic 2][pic 3][pic 4][pic 5]

Where were you/driver coming from at the time of the loss?[pic 6]

Where were you/driver going at the time of the loss?[pic 7]

What was the purpose of the trip?[pic 8]

What is the primary use of your vehicle?

Personal Use

Business/Commercial Use

At the time of the loss where you using the vehicle  for your business or occupation?[pic 9][pic 10][pic 11]

If yes, what is your business or occupation?[pic 12]

Is this vehicle ever used in the scope of your business or occupation?[pic 13]

How often?[pic 14]

Do you claim the vehicle as a deduction on your personal or business income tax return?[pic 15]

Was your vehicle repaired?[pic 16]

YES

NO        Repair cost $

When?

Where was it repaired?[pic 17][pic 18][pic 19][pic 20]

How many people were in your car?

How many people were in the other car?

Name and address of occupants of your vehicle who where injured (including yourself).[pic 21][pic 22][pic 23]

Medical treatment required?[pic 24]

YES

NO        If yes, hospital/doctor

Name and address of driver of other vehicle?[pic 25][pic 26][pic 27][pic 28]

Name and address of Occupants of other vehicle who were injured (including driver)?[pic 29][pic 30][pic 31]

Other Vehicle Year/Make:[pic 32][pic 33][pic 34][pic 35]

Vehicle License #:

Accident reported to Police?  _        NO If yes,        Which department? _        

Which driver received Ticket?  _        

What was the charge? _        

What plea was entered?  _        Guilty         _        Not Guilty        What was the court decision?  _        

Who witnessed the accident? Give name and address:  _        

Name of your insurance company:[pic 36][pic 37]

Name of company insuring other parties:[pic 38]

How did the accident happen? Give full account, starting speed and direction of each car:[pic 39][pic 40][pic 41][pic 42]

...