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Essay by brwncody • August 17, 2016 • Business Plan • 826 Words (4 Pages) • 737 Views
AFFIDAVIT OF ACCIDENT (All Questions Must be Answered)
Name of Owner of Car: _
Telephone No. _
Owner Address: _
Driver Name: _
Phone _
Age _
Driver Address: _
Place of Employment: _
Work Phone: _
Married or Single? _
(if married, spouse name) _
Date and Time of Accident: _
Location: _
Your Car Make:
Year
Model :
License No:
If you are not the driver of the vehicle at the time of loss, what is their relationship to you?[pic 1][pic 2][pic 3][pic 4][pic 5]
Where were you/driver coming from at the time of the loss?[pic 6]
Where were you/driver going at the time of the loss?[pic 7]
What was the purpose of the trip?[pic 8]
What is the primary use of your vehicle?
Personal Use
Business/Commercial Use
At the time of the loss where you using the vehicle for your business or occupation?[pic 9][pic 10][pic 11]
If yes, what is your business or occupation?[pic 12]
Is this vehicle ever used in the scope of your business or occupation?[pic 13]
How often?[pic 14]
Do you claim the vehicle as a deduction on your personal or business income tax return?[pic 15]
Was your vehicle repaired?[pic 16]
YES
NO Repair cost $
When?
Where was it repaired?[pic 17][pic 18][pic 19][pic 20]
How many people were in your car?
How many people were in the other car?
Name and address of occupants of your vehicle who where injured (including yourself).[pic 21][pic 22][pic 23]
Medical treatment required?[pic 24]
YES
NO If yes, hospital/doctor
Name and address of driver of other vehicle?[pic 25][pic 26][pic 27][pic 28]
Name and address of Occupants of other vehicle who were injured (including driver)?[pic 29][pic 30][pic 31]
Other Vehicle Year/Make:[pic 32][pic 33][pic 34][pic 35]
Vehicle License #:
Accident reported to Police? _ NO If yes, Which department? _
Which driver received Ticket? _
What was the charge? _
What plea was entered? _ Guilty _ Not Guilty What was the court decision? _
Who witnessed the accident? Give name and address: _
Name of your insurance company:[pic 36][pic 37]
Name of company insuring other parties:[pic 38]
How did the accident happen? Give full account, starting speed and direction of each car:[pic 39][pic 40][pic 41][pic 42]
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