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Full Name: License Plate #:
Email:
Phone: Requested Date:
Yes, this is an Autopac Claim.
For more info call 772-1100

Autopac Accident Report Form

Autopac Accident Report

Complete this Autopac Accident Report as soon as possible after the accident. Use it to help you make your Autopac Report.

Time: __________________ Date: ________________

Weather: __________________________________________________________

Light: _____________________________________________________________
(dark, dust, dawn, day)

Note: The Highway Traffic Act requires the driver of the vehicle
involved in an accident, to give written information to anyone that was
injured or whose property was damaged

OTHER DRIVER

Name: ____________________________________________________________

Address: __________________________________________________________

Telephone: ________________________________________________________

Driver's License #: __________________________________________________

Vehicle: ___________________________________________________________
(year, make, model, body type, hatchback)

License Plate #: ____________________________________________________

Vehicle Owner's Name: _______________________________________________

Insurance Company: _________________________________________________

Policy #: ___________________________________________________________

Insurance Agent: _____________________________________________________

Address: ___________________________________________________________

THE ACCIDENT

What happened? _____________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

accident report diagram

What injuries did people have? __________________________________________

___________________________________________________________________

___________________________________________________________________

WITNESSES

Name: ______________________________________________________________

Address: ___________________________________________________________

Telephone: _________________________________________________________

Name: ______________________________________________________________

Address: ___________________________________________________________

Telephone: _________________________________________________________

Call Police when:

  • A person has been injured
  • The damage to vehicles or property exceeds $1000
  • There has been vandalism, theft or a hit and run

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