Accident Checklist
Printable Version
| | DATE OF ACCIDENT |
| | DAY OF THE WEEK |
| | TIME OF DAY |
| | LOCATION OF ACCIDENT |
OTHER PARTY(s) INFORMATION
| | NAME |
| | ADDRESS |
| | PHONE NUMBER |
| | DRIVER'S LICENSE NUMBER |
| VEHICLE: | | MAKE | | MODEL | | YEAR |
| | LICENSE PLATE NUMBER |
| | REGISTER OWNER OF VEHICLE NAME |
| | INSURANCE COMPANY |
| | INSURED'S NAME |
| | POLICY NUMBER |
| | LOCATION OF DAMAGE ON VEHICLE |
| | STATEMENT OF OTHER PARTY AT ACCIDENT |
MY INFORMATION
| | LOCATION OF DAMAGE ON MY VEHICLE |
| | (1) WITNESS NAME |
| | ADDRESS |
| | PHONE NUMBER |
| | (2) WITNESS NAME |
| | PHONE NUMBER |
| | ADDRESS |
POLICE INFORMATION
LAPD CHP OTHER
| | POLICE REPORT NUMBER |
| | POLICE OFFICER NAME |
| | CALL CARPENTER & ZUCKERMAN (310) 273-1230 |