Accident Information Form

Aegis Service Corp. Insurance Services
30-50 Whitestone Expwy, Suite 401, Flushing NY 11354 
718-353-3800
(Print this form & keep it in your glove compartment)
  

Visit us online at http://www.AegisService.com


   Tab through to enter acquired information before re-printing and submitting to Insurance Company for claim processing.
  
  Time: AM PM   Street / Intersection: 
  Police Officer's Name:    Badge #:    Police Report #: 
  Brief Details  (traffic lights / signs, intersections, street names):
  

 
  Year:    Color:    License Plate#:  State:
  Make:    Model:   Number of passengers in your vehicle: 
  1. First / Last Name:     Home: ( ) -   Work: ( ) -
  Street Address:     City:    State:   Zip:
  Insurance Company Name:
   		  Insurance Policy Number:
   		  Driver's License Number:
 		   State:
 		   Date Of Birth:
   /    / 
 
  Year:    Color:    License Plate#:  State:
  Make:    Model:   Number of passengers in the other driver's vehicle: 
  1. First / Last Name (Driver of the vehicle):  
  Work Phone Number:
  ( ) -		   Home Phone Number:
  ( ) - 
  Street Address:     City:    State:   Zip:
  Insurance Company Name:
   		  Insurance Policy Number:
   		  Driver's License Number:
 		   State:
 		   Date Of Birth:
   /    / 
  2. First / Last Name (Registered owner if different):  
  Work Phone Number:
  ( ) - 		      Home Phone Number:
  ( ) -
  Street Address:     City:    State:   Zip:
  Insurance Company Name:
   		  Insurance Policy Number:
   		  Driver's License Number:
 		   State:
 		   Date Of Birth:
   /    / 
 
  1. First / Last Name:     Miscellaneous Info:   
  Street Address:     City:    State   Zip
  Driver's License Number
 

  State

  Date of Birth:
   /    /  		  Work Phone Number:
  ( ) -		   Home Phone Number:
  ( ) -
  2. First / Last Name:     Miscellaneous Info:   
  Street Address:    City:    State:   Zip:
  Driver's License Number
 

  State

  Date of Birth:
   /    /  		  Work Phone Number:
  ( ) -		   Home Phone Number:
  ( ) -
 
  1. First / Last Name:     Phone Number:  ( ) -  Home  Work
  Street Address:     City:    State:   Zip:
  2. First / Last Name:     Phone Number:  ( ) -  Home  Work
  Street Address:     City:    State:   Zip:

 
 
It may be useful to make a diagram on the back of this form showing the position of all vehicles involved in the accident.  
Include: direction vehicles were traveling, point of impact, location of traffic lights/signs & intersection with street names.