1 ATTENTION If You Were Involved in an Accident and You or Someone Else is Seriously Injured, Please Call 911 for Immediate Medical Help EMERGENCY DIAL 9-1-1 NOW Accident Date Day of Week Time AM PM Number of Vehicles Number Injured Number Killed WERE OTHERS INVOLVED IN THE ACCIDENT? Vehicle 2 Pedestrian Bicyclist PLEASE ENTER YOUR PHONE NUMBER: Phone YOUR INSURANCE CARD Please take a photo of your Insurance Card with Policy Number and drag and drop into the box below INSURANCE CARD OF OTHER PERSON INVOLVED IN ACCIDENT Please take a photo of each Insurance Card with Policy Number for each additional person involved in the accident and drag and drop into the box below YOUR DRIVER’S LICENSE Please take a photo of your Driver’s License or New York ID card and drag and drop into the box below DRIVER’S LICENSE OF OTHER PERSON INVOLVED IN ACCIDENT Please take a photo of each Driver’s License or New York ID Card for each additional person involved in the accident and drag and drop into the box below YOUR VEHICLE REGISTRATION Please take a photo of your Vehicle Registration and drag and drop into the box below VEHICLE REGISTRATION OF OTHER PERSON INVOLVED IN ACCIDENT Please take a photo of each Vehicle Registration for each additional person involved in the accident and drag and drop into the box below PHOTOS OF ACCIDENT DAMAGE Please take photos of damage to all motor vehicles involved in the accident and drag and drop into the box below VEHICLE INVOLVEMENT — Choose one of the following that describes the accident you were involved in: Two cars A pedestrian, bicyclist or other pedestrian an unoccupied vehicle more than two vehicles Did police investigate accident at scene? Yes No If “Yes”, Name of Police Agency or Precinct & Accident Number Next Share This Page:
