AUTOMOBILE ACCIDENT REPORT

Please furnish the following information for prompt handling of your claim.

    CLAIM INFORMATION

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    ACCIDENT INFORMATION

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    WITNESSES

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    INSURED'S VEHICLE AND DRIVER INFORMATION

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    PASSENGERS IN INSURED VEHICLE (ADDITIONAL PAPER IF NECESSARY)

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    PROPERTY DAMAGE TO OTHERS

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    PROPERTY DAMAGE TO OTHERS (CONTINUED)

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    PASSENGERS IN OTHER VEHICLE (USE ADDITIONAL PAPER IF NECESSARY)

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    STATE SPECIFIC FRAUD WARNING STATEMENT FOR PROPERTY LOSS CLAIM FORMS (PLEASE READ CAREFULLY)

    New Jersey: "Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Pennsylvania: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is crime and subjects such person to criminal and civil penalties" Alaska, Arkansas, Delaware, District of Columbia, Idaho, Indiana, Kentucky, Minnesota, New Hampshire, New Mexico, Ohio, Oklahoma, and Virginia "For your protection, these states require the following wording on this form: Any person who knowingly and with intent to defraud an insurer files a statement of claim containing false, inflated, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud and may be subject to civil fines, criminal penalties, and denial of insurance benefits." Applicable in All States For your protection, review your policy for an explanation of the insured's duties in the event of a loss. Failure to comply with these duties may void your policy
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