HR- Auto Accidents Report Form (Owned and Non-Owned vehicle)
| HR- Auto Accidents Report Form | |
| DRIVER'S INFORMATION | |
| Driver's First Name: |
Valeria
|
| Driver's Last Name: |
Bracero
|
| Driver's Phone Number: |
7875059012
|
| Email address (optional): | |
| Mailing address: | |
| VEHICLE INFORMATION | |
| Make: |
Ford
|
| Model: |
Fusion
|
| Year: | 2019 |
| Color: |
Blue
|
| Auto Insurance Company: |
Geico
|
| Insurance Policy Number: |
6041754745
|
| Accident Info | |
| Date of accident: | December 11, 2021, 7:29 p.m. |
| Accident location: |
Miami road
|
| Brief description of accident |
I had just left the store, I had forgotten to put the address in my phone, I was driving down Miami Miami road and I went to pull over I was going 5~6 miles per hour and she was walking on the side of the road where there was no sidewalk I didn’t see her until i heard the hit and I got out and asked if she was okay and called authorities.
|
| Was our driver at fault? | Yes |
| Any witness(es) |
1 witness
|
| Claim submitted to driver's insurance company? | No |
| Driver's claim number | |
| Did police show up to the scene? | Yes |
| Which Division (FHW, Local Police, City Police) |
Fort Lauderdale
|
| Crash report # |
342112205559
|
|
Provide any document given by the police |
|
|
|
| If Police did not show up, Provide any information exchanged with other party. | |
| Is our driver injured or will need medical attention? | No _ Ask Driver to fill out the medical waiver. |
| ADDITIONAL INFORMATION IS REQUIRED: | |
| AA Investigation -Suspension Acknowledgement Form required to be fill out by driver. | Checked |
| Detailed statement how accident occurred written by the driver. | Checked |
| Pictures of auto damages and scene of the accident. | Checked |
| Copy of DL and Insurance Card | Checked |
| Any documentation related to the accident including other party's information. | Checked |
| REPORTER INFORMATION | |
| First Name |
Christopher
|
| Last Name |
Louis
|
| Job Title | General Manager |
| Store Number: |
PJ 485 800 SE 17TH ST FORT LAUDERDALE, FL 33316 |
| WARM MANAGEMENT LLC7695 SW 104TH ST, STE 100 PINECREST, FL 33156 305.663.1750 EXT 204 | |
