GLOVE BOX
ACCIDENT REPORT FORM

We hope you are never involved in an accident, but if you are, we hope this form will assist you.
 
Also available in PDF Format.  

AFTER AN ACCIDENT
  • Stay Calm
  • If the vehicles are driveable and it is safe to do so, move them safely out of traffic
  • Apply first aid
  • Call police, and if necessary, ambulance.
  • Take brief notes

For 24-hour Claims Reporting and Emergency Assistance, call
1-800-319-9993
ACCIDENT DETAILS
Time of Accident:
____________ am / pm
Date of Accident:
______________________
day / month / year
Street:
________________________
City:
________________________
Province:
________________________
Speed:
Your kph:
__________
Other kph:
__________

Description of how the accident happened:

___________________________________

________________________________

____________________________________

Description of your vehicle's damage:

____________________________________

_________________________________

_____________________________________

 

Description of other vehicle's damage:

_____________________________________

_________________________________

_____________________________________
OTHER VEHICLE
Owner:
_______________________
Address:
_______________________
Phone:
Home:
 _________________
Work:
 _________________
Driver:
_______________________
Address:
_______________________
Phone:
Home:
 _________________
Work:
 _________________
Driver's licence No.:
 ________________________
Insurance Company:
 ________________________
Vehicle Make
 ________________________
Vehicle Year:
 ________________________
Number of Passengers:
 ________________________
Where treated:
 ________________________
Vehicle licence No.: ________________________
Policy No.: ________________________
Vehicle Model: ________________________
Vehicle Colour: ________________________
Name of injured: ________________________
INVESTIGATING OFFICER
Name:
 ________________________
Phone:
 ________________________
Badge No.:
 ________________________
Local Police Detachment:
 ________________________
WITNESS
Name:
_______________________
Address:
_______________________
Phone: Home: _________________
  Work: _________________

SKETCH OF ACCIDENT SCENE (try to estimate distances)
accident scene