Forms

 

Accident Form     

* Required

Title DR MISS MR MRS MS

First Name *

Last Name *

Email Address *

Date of Accident *

Time of Accident * -- Please select -- 1 2 3 4 5 6 7 8 9 10 11 12

AM/PM * AM PM

Location of Accident (Include City and State) *

Description of Accident *

Authority Contacted

Report #

Any violations/citations as a result of the Accident (Describe)

PROPERTY DAMAGE (not your vehicle) Describe Property (If Auto, year, make, model, plate#)

Insurance Company

Owner's Name and Address

Other Driver Name and Address (Check if same as owner) Same

Address (If different than owner)

Residence Phone Number

Business Phone Number

INJURED PARTIES Name and Address

Injured was Pedestrian In Your Car In other Car

Injured #2 Name and Address

Injured was Pedestrian In your car In other car

WITNESS OR PASSENGERS Witness or Passengers (Name and Address

Phone Number

Vehicle Insured Other

Other (Specify)

YOUR INSURED VEHICLE Year

Make

Model

Vin/Plate Number

State

Owners Name and Address

Residence Phone

Business Phone

Relation to insured (Employee, family etc

Date of Birth

Driver's License Number

State

Purpose of Use

Used with Permission Yes No

Describe Damage

Where can vehicle be seen

Other Insurance on Vehicle

Your Insurance Company Name

Your Policy Number

Your Agent's Name

Policyholder's Name and Address

Residence Phone

Business Phone

Remarks

ONLEY INSURANCE                    701 West Broadway • Winnsboro TX 75494                Phone: 800-517-4366 • Fax: 903-342-5432 • E-mail: bev@onleyinsurance.com