July 20, 2012
Agency
Auto Accident Guide
Knowing what to do after an accident will help you to remain calm and in control. It may even make the experience a little less frightening. Take a moment to review this guide, print it and keep it in the glove compartment of your vehicle so that you can use it in the event of an accident.
Your Information
Name:_______________________________Date:_____________Time:_________City:_________State:_______
Phone#:______________________________Email:__________________________________________________
Intersection or address where accident occurred:_____________________________________________________
Road Condition:_______________________________Weather:_________________________________________
What direction you were going:_________ Speed: _______Speed Limit:_______Police Dept:__________________
Police Report #:_______________ Accident Description:______________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Your Vehicle Year ________ Make_________Model_________Plate__________VIN#_________________________
Damage to YOUR Vehicle:________________________________________________________________________
Driver of Your Vehicle:_____________________Phone #_____________________
Other Driver’s Information:
Owners Name:______________________ Phone#:____________________Email:__________________________
Address:_________________________City:________________State:___________________Zip:_____________
Insurance Company:_______________________________Policy#:____________Effective Dates:______________
Drivers Name:_________________________Phone #:______________________Birthday:___________________
Drivers License #:_____________________ Year:_________Make:_________Model:_______________________
VIN#:_________________________________ Plate#:_____________________ Damage to Other Vehicle:______
___________________________
Injured Parties: List names, addresses, phone numbers and which vehicle they were in. Also list type of injuries
known. _____________________________________________________________________________________________
Witnesses: List names, addresses, phone numbers, which vehicle they were in or if they were independent
witnesses to the accident:________________________________________________________________________
CALL BERNARD E. PEDERSEN INSURANCE AGENCY IN PALATINE IL. AT 847-359-6070 IF YOU HAVE QUESTIONS
REGARDING YOUR CLAIM. YOUR INSURANCE COMPANY’S CLAIMS PHONE NUMBER IS LISTED ON YOUR AUTO
INSURANCE ID CARD LOCATED IN THE GLOVE COMPARTMENT OF YOUR VEHICLE. IF YOU DO NOT HAVE A
CURRENT AUTO INSURANCE ID CARD PLEASE CALL US OR EMAIL US TODAY!!
http://www.bepinsurance.com/
Safe driving to one and all and don’t forget to buckle up! It’s the law!!