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INFORMATION ON OTHER DRIVER: Name _________________________________________________________________________ Address________________________________________________________________________ Driver’s License #_____________State____________Expiration___________________________ Telephone (s)___________________________________________________________________ Auto Tag #__________________Make__________ Model________________ Color___________ INSURANCE INFORMATION: Company__________________________________Policy#___________________Expiration____ Date of accident________Time_________ WITNESSES: Name___________________________________Telephones_____________________________ Address________________________________________________________________________ Name___________________________________Telephones_____________________________ Address________________________________________________________________________ Name___________________________________Telephones_____________________________ Address________________________________________________________________________ Name___________________________________Telephones_____________________________ Address________________________________________________________________________ OTHER PERSONS: Name of Police Officer(s)___________________________________________________________ Name of Emergency Medical Personnel________________________________________________ YOUR ASSESSMENT OF: Personal Injury: _______________________________________________________________________________ Property Damages: _______________________________________________________________________________ Road Conditions, traffic flow, # of lanes each direction, traffic control (stop lights/stop signs): _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ DIAGRAM OF ACCIDENT AREA: |