8250 Woodfield Crossing Blvd Ste 330 Indianapolis IN 46240 www.hjspier.com info@hjspier.com 317-815-2800 (Main Line)	Commercial Lines Claims: 317-815-2803 Personal Lines Claims: 317-815-2802 After Hours Emergency: 317-363-9774

AUTOMOBILE ACCIDENT REPORT

DATE OF ACCIDENT:	TIME OF ACCIDENT:
LOCATION OF ACCIDENT:
OWNER OF VEHICLE:
ADDRESS:
HOME PHONE:	CELL PHONE:	WORK PHONE:
YR, MAKE/MODEL:
NAME OF INSURANCE COMPANY:
DRIVERS NAME (If Different):	RELATIONSHIP:
HOME PHONE:	CELL PHONE:	WORK PHONE:
INJURIES:
WHERE TREATED AND BY WHOM:
OCCUPANTS OF VEHICLES	AGE	RELATIONSHIP	INSURED VEHICLE	CLAIMANT VEH

DAMAGE TO PROPERTY OF OTHERS

OWNER OF VEHICLE:
YR, MAKE/MODEL:
DRIVERS NAME (If Different):
WHERE IS PROPERTY NOW:

WITNESSES (Include and Indicate Occupants of Cars)

NAME	ADDRESS	PHONE