NIC

NATIONAL INSURANCE COMPANY

Friendly Accident Report

Vehicle 1 - Vehicle and Owner Information (Insured)

E-Mail:

Physical Address:

State:

Zip Code


Postal Address:

State:

Zip Code:

Phones:
						Beeper Unit:

Policy Information
Policy Number:			Certificate No.:

Policy Efective/Expiration Dates and Accident Date and Time (mm/dd/yy)

Effective Date:

Expiration Date:

Date/Time of Accident:

Police Complaint No.:

Injured?

Yes

Was a policeman present at the site?

Yes

Information Insured Vehicle
Mortgagee:
Vehicle Information:

Make:		Model:		Year:
Color:		Mileage:

Driver Information
Are the owner and the driver of the vehicle the same?

Describe the Accident:

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