Automobile
Glove BoxKit

IF YOU HAVE AN ACCIDENT• Remain Calm
• Do not argue or admit liability.
• Gather the facts outlined on thereverse side.
• Call 1 (877) 567 7486 to report theloss.
• Your Policy number is:• Your Location (Plant) Code is:• Complete the reverse side of thisform and sign.
• Mail to the Tokio Marine office asadvised by the Customer Service Rep.
• Report all accidents to the local
police department, even if they were
not at the scene.
• Secure a local police report number.
• Do not give written or recorded
statement to anyone other than a
Police Officer or a representative of
Tokio Marine America.

PO Box 483
Jersey City, NJ 07303
Telephone: 1-877-567-7486

ACCIDENT DIAGRAM
Questions?
Please email us atclaim-account-coordination@TMAmerica.com

THE ACCIDENTDAMAGE TO PROPERTYOF OTHERSDATE: ____/ ____/ ____ TIME: ____: ____
ampm
PLACE: _________________________________________________________________________________________________________________PAVEMENT:

Dry

Wet

Ice/Snow

WEATHER: _____________________________________________________________________________________________________________
TRAFFIC CONTROL:
LightsSigns
None (Indicate on diagram)
DESCRIPTION OF ACCIDENT:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________POLICE REPORT #: _____________________OFFICER NAME: ________________________OTHER DRIVER’S:
NAME: ______________________________ADDRESS: ______________________________________________________________
CITY: ________________ STATE:________
LICENSE #___________________________OWNER OTHER VEHICLE:
NAME: ______________________________ADDRESS: _________________________________________________________________
CITY:________________ STATE:________
PLATE #: ____________________________
YEAR: _________ MAKE: _______________
MODEL: ______________________________
INSURANCE CO: ___________________________________________________________DAMAGE TO OTHER VEHICLE:____________________________________________________________________________DAMAGE TO PROPERTY (non-vehicle):__________________________________________________________________________________________________________________PROPERTY OWNER:____________________________________________________________________________ADDRESS: ______________________________________________________________
CITY:________________ STATE:________PASSENGERS & WITNESSESNAME: _________________________________ADDRESS: ____________________________________________________________________
CITY:___________________ STATE:_______PASSENGERWITNESSYOUR CAR
OTHER CAR
INJURED? ________________________________

NAME: _________________________________ADDRESS: ____________________________________________________________________
CITY:___________________ STATE:_______PASSENGERWITNESSYOUR CAR
OTHER CAR
INJURED? ________________________________

NAME: _________________________________ADDRESS: ____________________________________________________________________
CITY:___________________ STATE:_______PASSENGERWITNESSYOUR CAR
OTHER CAR
INJURED? ________________________________

NAME: _________________________________ADDRESS: ____________________________________________________________________
CITY:___________________ STATE:________PASSENGERWITNESSYOUR CAR
OTHER CAR
INJURED? ________________________________YOUR NAME: __________________________ADDRESS: _____________________________________________________________________
CITY:___________________ STATE:________PHONE:___ _____________________________
INJURED? ________________________________

SIGNATURE:___________________________