Information collection form
Driver 1 (Person who caused the accident)
Name: _________________________________________
Address: ______________________________________________
Driver’s License Number: _________________________
Driver’s License State: ____________________________
License Plate Number: ____________________________
Insurance Company: ______________________________
Policy Number: __________________________________
Effective Date of Policy: __________________________
Expiration Date of Policy: _________________________
Condition of roadway: [ ] Dry [ ] Wet
Weather conditions: [ ] Clear [ ] Raining [ ] Ice/Snow
Contributing factors: [ ] Speed [ ] Alcohol/Drugs
Additional Driver (use additional sheets of paper if there were more than three vehicles involved)
Name: _________________________________________
Address: _______________________________________
Driver’s License Number: _________________________
Driver’s License State: ____________________________
Telephone Number: ( _____ ) ______ - _________
Alternate Number: ( _____ ) ______ - _________
Witness (use additional sheets of paper if there are other witnesses)
Name: _________________________________________
Address: _______________________________________
Telephone Number: ( _____ ) ______ - _________
Alternate Number: ( _____ ) ______ - _________
Statement from witness:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
August 27th, 2008 | Category: Accidentes de Auto
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