Section A:
ACCIDENT SECTION:

* A-1: Date of Accident: (mm/dd/yyyy)
* A-2: Time of Accident:
     (click one)   AM    PM

* A-3: Location of Accident: (Enter exact addresse or detailed description)

* A-4: Description of Accident: (Give precise details)

* A-5: Authority Contacted & Report Number:

* A-6: List any Violations/Citations as a result of the accident and describe each.
     (If "None" enter "None")

Section P:
PROPERTY DAMAGED SECTION:
    (Not your vehicle)

* P-1: Describe Property Damaged.
     (If Auto(s) include year, make, model and license plate number(s))

P-2: Insurance Company for Damaged Property:

* P-3: Damaged Property Owner's Name:

* P-4: Damaged Property Owner's Address:
    (Include Street, City, State & Zip)

P-5: Owner's Residence Telephone Number:

P-6: Owner's Business Telephone Number:

P-7: If the Driver was other than the owner of the Damaged Vehicle, include Driver's name, address and contact information here:

* P-8: Driver's License Number of Damaged Vehicle's Driver:

* P-9: Describe the Damage:

P-10: Where Can Damage Be Seen?:

Section I
INJURED PARTIES:

Injured Person Number One:
* I-1: Name:
I-2: Age of Injured Person Number One:

* I-3: Address and Contact Info: (Include Telephone)

* I-4: Describe Injury:

Injured Number One Was: (choose one)
     Pedestrian  In Your Vehicle   In Other Vehicle

Injured Person Number Two:
I-5: Name:
Age of Injured Person Number One:

I-6: Address and Contact Info: (Include Telephone)

I-7: Describe Injury:

Injured Number Two Was: (choose one)
     Pedestrian  In Your Vehicle   In Other Vehicle

Section W
WITNESSES OR PASSENGERS:

Witness Number One:
* W-1: Name and Address:

* W-2: Telephone Number:

Witness Number Two:
W-3: Name and Address:

W-4: Telephone Number:

Section V
YOUR INSURED VEHICLE:

* V-1: Year:
* V-2: Make of Vehicle:
* V-3: VIN Number of Unit:
   
* V-4: License Plate Number:
* V-5: State of License:

* V-6: Owner of Vehicle - Name and Address:

Vehicle Owner's Telephone Numbers:
* V-7: Business:
V-8: Residence:

* V-9: Driver of Vehicle - Name and Address:

Driver Telephone Numbers:
* V-10: Business:
V-11: Residence:

V-12: Relation of Driver to Insured: (Employee, Family, etc.)

* V-13: Driver's Date of Birth: (mm/dd/yyyy)
* V-14: Driver's License Number:
* V-15: Driver's State of License:

* V-16: Describe Damage to Insured Vehicle:

* V-17: Where Can Vehicle Be Seen?

* V-18: Your Insurance Company Name:

* V-19: Insured Vehicle's Policy Number:

* Signed:
* Date: (mm/dd/yyyy)

IMPORTANT LEGAL NOTICE:
     By: 1: Signing above and faxing your Accident Report, or, 2: Typing your name and the date above and clicking the "Submit" button for online submission...
        You give legal authorization for the Allen Insurance Group, Underwriters, Surveyors or their designees to review your submission, to check relevant facts concerning your statements and possible coverages, to investigate this claim to their satisfaction.