Orange County NC Website
Browse       Search
<br />Including ALLIANCE OF NONPROFITS FOR INSURANCE (ANI) & <br />NONPROFITS INSURANCE ALLIANCE OF CALIFORNIA (NIAC) <br />www.insurancefornonprofits.org <br /> <br />Rev. 10/2014 Page 1 of 3 <br /> <br />Driver’s Collision Report Form <br /> <br />IN THE EVENT OF A COLLISION: <br /> <br /> <br />NONPROFIT / INSURED <br /> <br />Driver --- Complete all items to the best of your ability, sign and date page 3, and immediately give it to your supervisor. <br />Supervisor --- Fax this Driver’s Collision Report form to your insurance broker immediately. <br />BROKER Refer to our website for instructions on claim reporting. <br /> <br />If a claim needs to be reported after business hours or on the weekend, call (866) 718-1947. <br />This number is reserved for true claims emergencies after business hours and weekends. <br /> <br /> <br />Driver/Vehicle Information <br />Name of Driver (first and last) Driver’s Age Driver License No. State <br />Driver’s Address --- Street City State Zip Telephone No. <br /> ( ) <br />Name of Nonprofit / Employer ANI/NIAC Policy Number <br />Nonprofit/Employer Contact Name Contact Email Address <br />Nonprofit / Employer Address --- Street City State Zip Telephone No. <br />Make of Nonprofit’s Vehicle Body Type Year License Plate # V.I.N. (last four digits) <br />Damage to Nonprofit’s Vehicle: <br />Collision Information <br />Date of Collision <br /> <br />Day of Week (circle one) <br />Mon Tue Wed Thurs Fri Sat Sun <br />Time of Collision <br /> AM / PM <br />Location - Street or Highway & City <br />On what street were you driving? <br /> <br />Direction (circle one) <br />N S E W <br />Speed (approximate) <br />On what street was other vehicle driving? <br /> <br />Direction (circle one) <br />N S E W <br />Speed (approximate) <br />Police Report? <br /> Yes No <br />If yes, name of reporting officer Agency Citation/Report # <br />Witness #1 Name (first and last) <br /> <br />Telephone No. <br /> ( ) <br />Email Address <br />Witness #2 Name (first and last) <br /> <br />Telephone No. <br /> ( ) <br />Email Address <br />DocuSign Envelope ID: 81A61471-345A-47F9-8A2D-36F7929A6637