Shift Insurance Accident Form
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1
2Shift Insurance Services, LLC
5150 E. Candlewood St. 4B
WHAT TO DO
Lakewood CA, 90712
IN CASE OF AN ACCIDENT
562-714-9424
1.
STOP IMMEDIATELY and give
assistance to involved parties.
THE ACCIDENT
DIAGRAM OF ACCIDENT
IF SOMEONE IS HURT, obtain
2.
appropriate medical attention (i.e.,
Show names of streets, and also directions in
□
□
call an ambulance).
Date_____________ Hour _________
AM
PM
which vehicles were going, indicate clearly by
N., S., E. or W.
CALL THE POLICE to assist and
3.
Location:
investigate the accident.
Street Address ________________________________
City and State ________________________________
EXCHANGE DRIVER, VEHICLE
4.
Driving which way? ____________________________
AND INSURANCE INFORMATION
□
□
with involved parties.
Were your lights on?
Yes
No
COMPLETE THIS FORM AT THE
5.
Condition of weather
ACCIDENT SCENE. Fill in all
information requested.
____________________________________________
____________________________________________
DO NOT DISCUSS THE
6.
ACCIDENT FACTS with anyone
Road conditions
except the police, your insurance
____________________________________________
agent or a properly identified
____________________________________________
representative of your insurance
company.
POLICE INFORMATION
Describe how the accident occurred
DO NOT ADMIT OR DISCUSS
Name of Police Department
7.
____________________________________________
FAULT for the accident.
_____________________________________
____________________________________________
Name of Officer ________________________
____________________________________________
IF YOU HAVE A CELL PHONE,
8.
____________________________________________
take pictures.
Accident Report No. ____________________
____________________________________________
REPORT THE ACCIDENT TO
9.
____________________________________________
□
□
Citation Issued?
Yes
No
YOUR INSURANCE AGENT OR
____________________________________________
INSURANCE COMPANY as soon
____________________________________________
as possible.
If yes, against whom?
____________________________________________
____________________________________________
__________________________________
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