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Print and Keep This In Your Glove Box

This document contains important information and should be completed in case of an accident

Remain at the scene of the accident and stay calm.
Notify the police.
Exchange information with other driver.

Other Driver
Name:	_________________________________
Address:	_________________________________
Telephone Number:	_________________________________
Driver's License Number:	_________________________________
Insurance Company:	_________________________________
Policy Number:	_________________________________
Year, Make, Model, Color of Vehicle:	_________________________________
License Tag Number:	_________________________________

Other Owner (If not the driver):
Name:	_________________________________
Address:	_________________________________
Telephone Number:	_________________________________
License Number:	_________________________________
Insurance Company:	_________________________________
Policy Number:	_________________________________

Witness 1
Name:	_________________________________
Address:	_________________________________
Telephone Number:	_________________________________

Witness 2
Name:	_________________________________
Address:	_________________________________
Telephone Number:	_________________________________

Passenger
Name:	_________________________________
Address:	_________________________________
Telephone Number:	_________________________________

Passenger
Name:	_________________________________
Address:	_________________________________
Telephone Number:	_________________________________

Statement by Other Driver:

_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

Police
Police Department:	_________________________________
Investigating Officer:	_________________________________
Badge Number:	_________________________________
Report Number:	_________________________________

Accident Information
Date of Accident:	_________________________________
Time of Accident:	_________________________________
Weather Condition:	_________________________________
Accident Diagram:

Show the following:
Street you were on:	_________________________________
Your direction of travel:	_________________________________
Street other driver was on:	_________________________________
Other driver's direction of travel:	_________________________________

If you would like us to mail you a copy of this brochure, just e-mail us your request.

There is never a charge to discuss a case and there are no fees in personal injury cases unless we recover money for you. To discuss any legal matter of importance to you, call Harold Semanoff, Esquire, a member of the firm.

Semanoff Ormsby Greenberg & Torchia, LLC
Attorneys At Law
2617 Huntingdon Pike
Huntingdon Valley, PA 19006
Telephone: (215) 887-0200
Fax: (215) 884-3500

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