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 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