HBI Accident Investigation Preview * Report all collisions promptly, especially those involving serious injury or death * Carefully examine all damage to vehicles and property Your Vehicle Driver's Name Company Name Policy # Phone # Driver's Lic. # Lic. Plate # Photo of Driver's License Drop files here or Select files Max. file size: 120 MB, Max. files: 1. Make of Vehicle Model Year Date MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM Damage to your vehicle? Yes No If Yes, Where? Location of Accident Location of Accident Street Address Address Line 2 City State / Province / Region Injuries Are you Injured? Yes No If Yes, describe injury Conditions Pavement Dry Wet Ice Snow Weather Visibility Traffic Control Lights Signs None Police Police Investigation? Yes No Name of Police or Sheriff Dept. Citation Issued? Yes No To Whom Other Vehicle Driver's Name Company Name Policy # Phone # Photo of Insurance Card Drop files here or Select files Max. file size: 120 MB, Max. files: 1. Driver's Lic. # Lic. Plate # Photo of Driver's License Drop files here or Select files Max. file size: 120 MB, Max. files: 1. Make of Vehicle Model Year Damage to other vehicle? Yes No If Yes, Where? Other Vehicle Injuries Are they Injured? Yes No If Yes, describe injury Witnesses Witness Name, Address, and Phone # Add Remove Property Damage Other Than Vehicles Was there property damage other than vehicles? Yes No Owner Address Street Address Address Line 2 City State / Province / Region PhoneWhat was damaged Location of property List All Passengers or Other Persons InvolvedWere there any other passengers or other persons involved? (1) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Were there any other passengers or other persons involved? (2) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Were there any other passengers or other persons involved? (3) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Were there any other passengers or other persons involved? (4) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Were there any other passengers or other persons involved? (5) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Were there any other passengers or other persons involved? (6) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Were there any other passengers or other persons involved? (7) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Were there any other passengers or other persons involved? (8) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Were there any other passengers or other persons involved? (9) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Were there any other passengers or other persons involved? (10) Yes No Name, Address, and Phone #NameAddressPhone Number Add RemoveWhere Your Vehicle Other Vehicle Pedestrian Injured? Yes No If yes, describe Describe what happened(Required)Photos of Accident (at least 5) include surroundings (Required) Drop files here or Select files Max. file size: 120 MB. Drivers SignatureAdditional Email 1 Send a notification to an additional emailAdditional Email 2 Send a notification to an additional email
