Claimant Information 1. Name of Injured Party DOB Employee Client Volunteer Visitor Other -- Address -- Street City State Zip Home Phone # Business Phone # Email Address ( ) ( ) Description of Injury (nature and extent of; please be specific): Transported by Ambulance Yes No Name and Phone # of Hospital or Doctor, if applicable Observations of Nonprofit Claimant’s Attire/Description of Clothing (i.e., shorts, t-shirt) Type of Shoes Was Claimant carrying anything? (if yes, what) No Yes -- Describe claimant’s demeanor when making the report (i.e., agitated, in obvious or no obvious pain, able to move around while describing what happened, etc.) Claimant Information (use the back of the form or attach an additional sheet of paper if needed) 2. Name of Injured Party DOB Employee Client Volunteer Visitor Other -- Address -- Street City State Zip Home Phone # Business Phone # Email Address ( ) ( ) Description of Injury (nature and extent of; please be specific): Transported by Ambulance Yes No Name and Phone # of Hospital or Doctor, if applicable Observations of Nonprofit Claimant’s Attire/Description of Clothing (i.e., shorts, t-shirt) Type of Shoes Was Claimant carrying anything? (if yes, what) No Yes -- Describe claimant’s demeanor when making the report (i.e., agitated, in obvious or no obvious pain, able to move around while describing what happened, etc.) (use the back of the form or attach an additional sheet of paper if needed) PRINT NAME OF INDIVIDUAL COMPLETING THE FORM SIGNATURE DATE
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
Description of Collision (include weather and road conditions): (Use the back of this sheet if additional space is needed; please use the diagrams on page 3 to draw the collision) Passenger(s) in Your Vehicle (attached additional pages if needed) Name (first and last) Telephone No. ( ) Email Address Age Injuries? Yes No Name Telephone No. ( ) Email Address Age Injuries? Yes No Name Telephone No. ( ) Email Address Age Injuries? Yes No Ambulance called to scene? Yes No Name of doctor or hospital Other Vehicle Involved Name of Driver (first and last) Driver License No. State Address - Street City/State/Zip Telephone No. ( ) Email Address Name of Vehicle Owner (if different than above) Telephone No. ( ) Email Address Name of Insurance Company Policy # Telephone No. ( ) Year/Make of Vehicle Body Type License Plate No. State Damage to Vehicle: Passenger’s Name (first and last) Telephone No. ( ) Email Address Age Injuries? Yes No Passenger’s Name (first and last) Telephone No. ( ) Email Address Age Injuries? Yes No Other Vehicle Involved (if an ) Name of Driver (first and last) Driver License No. State Address - Street City/State/Zip Telephone No. ( ) Email Address Name of Vehicle Owner (if different than above) Telephone No. ( ) Email Address Name of Insurance Company Policy # Telephone No. ( ) Year/Make of Vehicle Body Type License Plate No. State Damage to Vehicle: Passenger’s Name (first and last) Telephone No. ( ) Email Address Age Injuries? Yes No Passenger’s Name (first and last) Telephone No. ( ) Email Address Age Injuries? Yes No