Shift Insurance Accident Form Page 2
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2Your Policy #
Shift Insurance Services, LLC
_______________________________
5150 E. Candlewood St. 4B
Lakewood CA, 90712
Your Claim #
562-714-9424
_______________________________
INFORMATION OF OTHER PARTY INVOLVED
INFORMATION OF OTHER PARTY INVOLVED
Name of Driver _________________________________________________
Name of Driver _________________________________________________
Address ______________________________________________________
Address _______________________________________________________
Telephone Number _____________________________________________
Telephone Number ______________________________________________
Driver's License No. _____________________________________________
Driver's License No. _____________________________________________
Make and Year of Vehicle _________________________________________
Make and Year of Vehicle ________________________________________
Vehicle License Plate ____________________________________________
Vehicle License Plate ___________________________________________
Describe Damages ______________________________________________
Describe Damages ______________________________________________
_____________________________________________________________
______________________________________________________________
Insurance Co. Name and Policy No. ________________________________
Insurance Co. Name and Policy No. _________________________________
_____________________________________________________________
______________________________________________________________
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Pictures Taken:
Yes
No
Pictures Taken:
Yes
No
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Bodily Injury Sustained:
Yes
No
Bodily Injury Sustained:
Yes
No
If so explain ___________________________________________________
If so explain ___________________________________________________
_____________________________________________________________
_____________________________________________________________
WITNESSES
ADDITIONAL NOTES
Name ________________________________________________________
_________________________________________________________
Address ______________________________________________________
_________________________________________________________
Telephone No. _________________________________________________
_________________________________________________________
_________________________________________________________
Name ________________________________________________________
_________________________________________________________
Address ______________________________________________________
_________________________________________________________
Telephone No. _________________________________________________
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