Accident Information Card  Send To Printer  

(Print out this card and carry a copy in all of your vehicles at all times)

Ken Marchio Auto Body

950 West Elm

Hanover, PA

717-637-9598

Pennsylvania State law says that you may have the shop of your choice make the repairs on your vehicle. You are not required to use a shop selected by a claims adjuster.

 

Fill out the position of all vehicles in the graph above:

Your Information:

Your Insurance Company and Agent

Your Policy Number

Date of Accident†††††††††††††††††††††††† †††††††††††††††††††††††††††††††††††††††††††††††††††††Time of Accident

Location

Always carry a disposable camera in your car Ė take pictures of everything and everybody

Other Driverís Information:

Other Driverís Name

Other Driverís Address

City†††††† †††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††State†††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Zip Code

Year, Make ,Color, Model of other vehicle

License Plate #

Drivers License # (including State of Issue)

Insurance Company and Agent

Policy Number

Was the other driver wearing glasses?

Witness #1

Name††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

Address

City††††††††††††††††††††††††††††††††† State†††††††††††††††††††††††††††††† Zip††††††††††††††††††††††††††††††††††††† Phone

Witness #2

Name††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

Address

City††††††††††††††††††††††††† ††††††††State†††††††††††††††††††††††††††††† Zip††††††††††††††††††††††††††††††††††††† Phone

Witness #3

Name††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

Address

City††††††††††††††† ††††††††††††††††††State†††††††††††††††††††††††††††††† Zip††††††††††††††††††††††††††††††††††††† Phone

Use the back of this paper to record any other observations or notes

Call Ken Marchio Auto Body:

717-637-9598