Automobile Accident Report



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Marsh Canada Limited

Canada Trust Tower – BCE Place

161 Bay Street, Suite 1400

Toronto, Ontario M5J 2S4



Telephone 416 868 2600

Automobile Accident Report F9301-03 : 2000/04/20

Marsh Canada Contact -      : Tel.: (416)       Fax: (416) 868-2150

Insurance Company:       Policy No.:      

INSURED

Registered Owner:       Phone:      

Lessee:       Phone:      

Address:      

DRIVER

Name       Driver’s License No.:       Age:      

Address:      

Vehicle was used for: Business Pleasure

YOUR
VEHICLE


Year:       Make:       Type:       Serial No.:       License No.:      

Describe Damage:      

Where is Vehicle now?       Estimate: $      

TIME AND PLACE

Date of Accident:       Time:       A.M. P.M.

Place:       Town:       Province:      

DAMAGE TO
PROPERTY
OF OTHERS


Owner:       Address:      

Driver:       Address:      

Automobile: Year:       Make:       License No.:       Phone:      

Describe Damage:       Estimate: $      

Insurance Company:       Policy No.:      

PERSONS
INJURED


Names Addresses Ages

                 

                 

                 

Injuries:      

POLICE

Yes No Name of Officer:       Badge No.:       Station:      

INDEPENDENT
WITNESSES


Names Addresses Phone Nos.

                 

                 

                 

ADJUSTER

Name of Adjusting Company:       When:      

DETAILS OF ACCIDENT:

     


     

     


Signature

Date (mm/dd/yyyy)
     

(Use reverse side for diagram or additional information.)


D
ESCRIPTION OF ACCIDENT





     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

SIGNATORY

Signature

Date (mm/dd/yyyy)
     


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