Title Page
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When describing this incident do NOT place blame nor make any assumptions. Please only record facts and attach as many relevant photos as possible.
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Site conducted
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Report Completed on
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Report Prepared by
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Location where report was completed
Artio Vehicle Involved
Collision Details
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Was the vehicle occupied at the time of collision?
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Driver's Name
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Were there any other occupants?
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Who else was in the vehicle?
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Date and Time of the Collision
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Location of the Collision
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Brief Description of the Collision
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Did the Police come to the scene.
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Police Department
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Police Report #
Artio Vehicle Information
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Briefly describe damage to Artio's Vehicle
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Is the vehicle drivable or was it towed?
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Did the airbags deploy?
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Was anyone in Artio's vehicle Injured?
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Name(s) of injured party(s)
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Please fill out an Injury Incident Form for each Injured Party
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Adjuster Please Contact Lee Terwilliger Director of Safety at 484-253-8114 or lterwilliger@artiotrafficprotection.com
Other Party(s) Information
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Was another vehicle involved?
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Year
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Make
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Model
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Last 5 Digits of Vin
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Briefly Describe Damage to vehicle and the location of the damage
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Is the vehicle drivable or was it towed?
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Did airbags deploy?
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Name of Driver
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Names of any Passengers (if applicable)
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Was anyone in this vehicle injured?
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Names of injured parties (if known)
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Was an additional vehicle involved?
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Year
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Make
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Model
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Last 5 Digits of Vin
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Briefly Describe Damage to vehicle and the location of the damage
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Is the vehicle drivable or was it towed?
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Did airbags deploy?
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Name of Driver
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Names of any Passengers (if applicable)
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Was anyone in this vehicle injured?
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Names of injured parties (if known)
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Was an additional vehicle involved?
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Year
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Make
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Model
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Last 5 Digits of Vin
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Briefly Describe Damage to vehicle and the location of the damage
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Is the vehicle drivable or was it towed?
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Did airbags deploy?
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Name of Driver
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Names of any Passengers (if applicable)
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Was anyone in this vehicle injured?
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Names of injured parties (if known)
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Was an additional vehicle involved?
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Year
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Make
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Model
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Last 5 Digits of Vin
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Briefly Describe Damage to vehicle and the location of the damage
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Is the vehicle drivable or was it towed?
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Did airbags deploy?
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Name of Driver
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Names of any Passengers (if applicable)
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Was anyone in this vehicle injured?
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Names of injured parties (if known)
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Was an additional vehicle involved?
