Including ALLIANCE OF NONPROFITS FOR INSURANCE (ANI) & NONPROFITS INSURANCE ALLIANCE OF CALIFORNIA (NIAC) Report Form Driver’s Collision IN THE EVENT OF A COLLISION: / Driver -- Complete all items to the best of your ability, sign and date page 3, and NONPROFIT INSURED immediately give it to your supervisor. Supervisor -- Fax this Report form to your insurance Driver’s Collision broker immediately. Refer to our website for instructions on claim reporting. BROKER If a claim needs to be reported after business hours or on the weekend, call (866) 718-1947. This number is reserved for true claims emergencies after business hours and weekends. Driver/Vehicle Information Name of Driver Age Driver License No. State (first and last) Driver’s Address -- Street City State Zip Telephone No. Driver’s ( ) Name of Nonprofit / Employer ANI/NIAC Policy Number Nonprofit/Employer Contact Name Contact Email Address Nonprofit / Employer Address -- Street City State Zip Telephone No. Make of Body Year License Plate # V.I.N. (last four digits) Nonprofit’s Vehicle Type Damage to Vehicle: Nonprofit’s Collision Information Date of Collision Day of Week Time of Collision Location - Street or Highway & City (circle one) Mon Tue Wed Thurs Fri Sat Sun AM / PM On what street were you driving? Direction Speed (circle one) (approximate) N S E W On what street was other vehicle driving? Direction Speed (circle one) (approximate) N S E W Police Report? If yes, name of reporting officer Agency Citation/Report # Yes No Witness #1 Name Telephone No. Email Address (first and last) ( )
Including ALLIANCE OF NONPROFITS FOR INSURANCE (ANI) & NONPROFITS INSURANCE ALLIANCE OF CALIFORNIA (NIAC) Driver’s Collision Report Form IN THE EVENT OF A COLLISION: NONPROFIT / INSURED Driver -- Complete all items to the best of your ability, sign and date page 3, and immediately give it to your supervisor. Supervisor -- Fax this Driver’s Collision Report form to your insurance broker immediately. BROKER Refer to our website for instructions on claim reporting. If a claim needs to be reported after business hours or on the weekend, call (866) 718-1947. This number is reserved for true claims emergencies after business hours and weekends. Driver/Vehicle Information Name of Driver (first and last) Driver’s Age Driver License No. State Driver’s Address -- Street City State Zip Telephone No. ( ) Name of Nonprofit / Employer ANI/NIAC Policy Number Nonprofit/Employer Contact Name Contact Email Address Nonprofit / Employer Address -- Street City State Zip Telephone No. Make of Nonprofit’s Vehicle Body Type Year License Plate # V.I.N. (last four digits) Damage to Nonprofit’s Vehicle: Collision Information Date of Collision Day of Week (circle one) Mon Tue Wed Thurs Fri Sat Sun Time of Collision AM / PM Location - Street or Highway & City On what street were you driving? Direction (circle one) N S E W Speed (approximate) On what street was other vehicle driving? Direction (circle one) N S E W Speed (approximate) Police Report? Yes No If yes, name of reporting officer Agency Citation/Report # Witness #1 Name (first and last) Telephone No. ( ) Email Address
Accident%20Claim%20Form.docx