IF YOU ARE INVOLVED IN AN ACCIDENT

1.
2.
3.
4.
5.

STOP IMMEDIATELY - CALL A POLICE OFFICER

Call for EMERGENCY HELP if someone is HURT.
TAKE names, addresses & phone numbers of all WITNESSES: Including people in other vehicles involved.
COMPLETE this report AT THE SCENE OF THE ACCIDENT. Fill in ALL information asked for.
DO NOT give any information concerning accident, other than your Insurance ID Card, to anyone UNLESS they have
licensed authority: Such as a POLICE OFFICER.
6. REPORT ACCIDENT IMMEDIATELY to your SUPERVISOR and to the YAMAHA FLEET ADMINISTRATOR

Bobbi-Ext. 4111 Cell (678) 296-0978 John Allison (714) 761-7459 or Genevieve Monreal (714) 761-7765 / FAX # (714) 761-7840
YMUS VEHICLE:
Year

Make

Model

Vehicle I.D./Vin #

Name

Address

City
1000 Hwy 34 E
Address

License #

Driver:
Employed By:

YMMC
Company (YMUS, YMMC, YGC, Boat Co., etc.)

THE ACCIDENT:
Date:

Hour:

Was accident reported to police?

Yes [ ] No [ ]
Describe how accident happened:

Phone #
GA

City:
am
pm

Direction you were driving: Speed

N[ ]S[ ]E[ ]W[ ]
Describe Weather Conditions:

State Zip
Newnan
City

State:

Street & Nearest Cross Street

How far from Right curb were you?

Headlights ON?
Yes [ ] No [ ]

Describe Road Conditions:

Officer Name: Badge #

Did the Vehicle (#1) contribute to the accident?

Which Police Dept.

Police Report #

Yes [ ] No [ ]

Describe Damages:

DIAGRAM:
Fill in street names. Indicate directions in which the vehicles were going*
#1

Your Vehicle (# 1)

#2

Draw a diagram using:

Other Vehicle/s (# 2, etc.)
*Mark points of compass (N-S-E-W)

30265

IF YOU ARE INVOLVED IN AN ACCIDENT

SEE OTHER SIDE

IF YOU ARE INVOLVED IN AN ACCIDENT

DAMAGE TO PROPERTY OF OTHERS:
Owner's Name:

Address:

Phone #

Driver's Name:

Address:

Phone #

2
3
Description of other vehicle/s:

Describe damages to other vehicle/s:

1

Year

Make

I.D.# / Vin#

Model
License #

2
Year

Make

I.D.# / Vin#

Model
License #

3
Year

Make

I.D.# / Vin#
INJURED PERSONS:
Name:

Model
License #

Address:

Phone #

( )

( )

3
Describe injuries:

( )
Where was injured person taken after accident?

1
2
3
WITNESS INFORMATION:
Name

Address:

Phone #

( )

( )

X
SIGNATURE

In order to process your claim quickly please FAX "Cost to Repair" estimates from a
body shop as soon as possible to Genevieve Monreal / Fleet Support (714) 761-7840.
Please forward signed Original to:
ATTN: VEHICLE SUPPORT
YMUS
6555 KATELLA AVE

IF YOU ARE INVOLVED IN AN ACCIDENT

CYPRESS CA 90630

IF YOU ARE INVOLVED IN AN ACCIDENT

# (714) 761-7840

GA

30265
State Zip

hts ON?
No [ ]

eport #

E-W)

HER SIDE

IF YOU ARE INVOLVED IN AN ACCIDENT

cident?

IF YOU ARE INVOLVED IN AN ACCIDENT

IF YOU ARE INVOLVED IN AN ACCIDENT