Title Page

  • Insurance Provider

  • Policy number

  • Policy holder

  • Conducted on

  • Inspected by

  • Address

Car Insurance Inspection

Loss

  • Date

  • Location

  • City

  • State

  • Police Dept. Involved

  • Ticket Issued

Description of Accident

  • Describe the accident in detail

Insured Vehicle

  • Year

  • Make

  • Model

  • V.I.N

  • Plate Number

  • Extent of Damages

  • Present Location

  • Driver Name

  • Date of Birth

  • License Number

  • State

Other Vehicle (if applicable)

  • Year

  • Make

  • Model

  • Extent of Damages

  • Owner

  • Phone Number

  • Plate Number

  • City

  • State

  • Address

  • Zip

Insurance Information

  • Company Name

  • Policy Number

  • Agent Name

  • Phone Number

Injured

  • Name

  • Phone Number

  • Address

  • City

  • State

  • Zip

  • Extent of Injury

Witnesses

  • Name

  • Phone Number

  • Address

  • City

  • State

  • Zip

Impact

  • Is damaged auto essential to business?

  • How?

Completion

  • Completed by

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