Automobile Accident Report Form - Insurance Coverage Office
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1
2STATE OF DELAWARE
INSURANCE COVERAGE OFFICE
97 Commerce Way
Suite 201
Phone: (302) 739-3651
Dover, DE 19904
Fax: (302) 739-5345
Email: inscov@state.de.us
Toll Free: (877) 277-4185
Automobile Accident Report
State Agency
If Other
INSURED
Address
Phone #
City
State
Zip
Date
AM
Time
PM
TIME & PLACE
Location
OF
ACCIDENT
City
State
Make & Model
Year
VIN #
Tag No.
Driver
Empl Id.
STATE OWNED
Address
Home Phone No.
VEHICLE
City
State
Zip
(# 1)
Years Licensed
Employed By
Age
For what purpose was vehicle being used?
Owner
DAMAGE
Describe Damage
TO STATE OWNED
VEHICLE (# 1)
Est. cost of repairs $
Where vehicle may be seen
Make & Model
Tag No.
Year
Owner's Name
Phone #
OTHER
Owner's Address
VEHICLE
City
State
Zip
(# 2)
Driver's Name
Phone #
Driver's Address
State
Zip
City
Insurance Carrier
Policy #
Describe Damage
DAMAGE
TO OTHER
Est. cost of repairs $
Where vehicle may be seen
VEHICLE (# 2)
Describe Damage
OTHER
PROPERTY
Address
Owner
DAMAGE
Est. cost of repairs $
Where damaged property may be seen
NAME
AGE
ADDRESS
YOUR
1
PASSENGERS
2
3
4
ADDRESS
NAME
AGE
WITNESSES
1
(not involved in
2
accident)
3
4
NAME
AGE
ADDRESS
INJURED
1
PERSONS
2
3
4
EXTENT
1
OF
2
INJURIES
3
4
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Parent category: Business