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

* required  
Name
Address
Postal code
Home phone
Work phone
Cell phone
Other phone
eMail address *


Incident Information

 
Date of loss  dd-mmm-yyyy *
Time of loss AM PM
Number of vehicles involved
Location (city)  *
Street
Cross street


Vehicle(s) Information

   

  Vehicle 1 Vehicle 2 Vehicle 3
Plate numbers
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