Insurance Company FARMERS ]AR]TIERS Accident BeIort Ialmels Policyholders Gall: 1-800-435-fr64 or logonto ww.farmerc.Gom to lenolt a loss01 checl ona claim. @ FARMERS w Phone # Policy # Expiration date Registration informationon other vehicle Name and address of the reqistered owner Address VIN # Expiration Date 6. Occupants of other vehicle A. Name Address Phone # Age Age O Female O Male B. Name O Female O Male Address Fillout this report ascompletely aspossible. 1. 2. Time Date Police called? O Yes O No 3. Name of Address other driver Phone # Drive/s License # License Plate # 4. Policereporttaken? OYes O No Report # Witness information A. Name Address Phone # Name Address Phone # 7. # of Injuries? Your own Your passengers Pedestrians Other driver Their passengers 8. Location ofaccident 9. Direction of travel OtherVehicle YourVehicle l0.Speed oftravel Other vehicle Your vehicle 11.Area of damage Other vehicle Your vehicle Phone # Make sure you complete the diagram on the back