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Accident Report Form
Print this form and keep it with your liability card in your car.
| CIS
Insurance Brokers (905) 889-2268 |
| Accident Summary: |
| Time: |
Date: |
| Location:
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| Third Party Details: |
| Insurance Co.: |
Policy#: |
| Agent: |
Phone: |
| Address:
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| Driver Name: |
Phone: |
| Vehicle: |
| Witness Name: |
Phone: |
| Police Constable Name: |
| Division No. |
Badge No. |
| Phone No. |
Report No. |
| Traffic Charge Laid? |
Copyright © 1999-2009 CIS Insurance Brokers (Canada) Ltd. All rights reserved.
Revised: June, 2010
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