Newberry Insurance Agency, Inc.

1760 Ellington Rd.
South Windsor, CT 016074

Phone: 860-644-3049     Fax: 860-644-7789

Please be advised that insurance coverage cannot be bound, modified, or terminated by e-mail messages or information provided to us via the web. Any information you submit will be used solely for the purpose of quoting insurance options, and does not in any way constitute an agreement of coverage.

Auto Accident Report Form

Full Name:
Address: City:
Mail Address (if different): State: Zip:
Email: Home Phone: (with area code)
Office Phone: (with area code)
Ext: 		Fax: (with area code)
Best time to contact:

About the Accident

  1. Date accident occurred (DD/MM/YY)

    //

  2. Was your vehicle drivable?

    Yes No

  3. Was the other vehicle drivable?

    Yes No

  4. Location the accident occurred

    City:

    Street:

  5. Did the police respond to the accident?

    Yes No

    If yes, what police department? (town)

    Were there any citations issued? Yes No

    If yes, to whom?

  6. Name of person driving your car at time of accident:

  7. Do you own the vehicle?

    Yes No

    If no, please list owner information:

    Full Name:

    Street Address:

    Mailing Address: (if different)

    City: State: Zip:

    Phone:

    8. Your Vehicle Information

  8. Year (i.e. 1995)

  9. Make

  10. Model

  11. Plate #

  12. Description of damage

    13. The Other Vehicle's Information

  13. Full Name:

    Street Address:

    Mailing Address: (if different)

    City: State: Zip:

    Phone:

  14. Name of their insurance company

  15. Other drivers's license number if known

  16. Year (i.e. 1995)

  17. Make

  18. Model

  19. Plate #

  20. Registration #

  21. Description of damage to other vehicle

    22. Witnesses

  22. Witness 1

    Full Name:

    Street Address:

    Mailing Address: (if different)

    City: State: Zip:

    Phone:

  23. Witness 2

    Full Name:

    Street Address:

    Mailing Address: (if different)

    City: State: Zip:

    Phone:

  24. Questions and/or Comments

Important Note: If possible please fax a copy of the police report to Newberry Insurance Agency, Inc.860-644-7789