Witness Information Form

Note:
* To report suspicious, exaggerated or fraudulent claims please call 604-661-6844 or toll free 1-800-661-6844. Tip information is confidential and callers can remain anonymous.

Witness Information

Name

Address

Postal code

Home phone

Work phone

Cell phone

Other phone

Email address

Incident Information

Date of loss

mmm

yyyy

Time of loss

a.m.

p.m.

Number of vehicles involved

Location (city)

Street

Cross street

Vehicle(s) Information

Vehicle 1

Plate number

Colour

Year

Make

Model

Damaged area

Vehicle 2

Plate number

Colour

Year

Make

Model

Damaged area

Vehicle 3

Plate number

Colour

Year

Make

Model

Damaged area

What happened/Comments

If required, can we provide your name, phone number and a copy of this report to the police?

Yes No

* required fields