MOTOR ACCIDENT REPORT FORM (Page 1 of 2)

(to be completed fully and returned immediately)

PLEASE READ THE REMINDERS AT THE NEXT PAGE
Assured’s Name Policy No.

Address Email Address Tel. No./Mobile No.

Insured Vehicle Conduction Sticker No./Plate No.

Nature of Loss: Own Dmage Third Party damage/Injury Place of Loss

Assured Info Third Party Info

Driver’s Name Driver’s Name

Address Address

Driver’s License No. License Type: Prof. N. Prof. Driver’s License No. License Type: Prof. N. Prof.
Student Foreign/International Student Foreign/International
Date & Place of Issuance Expiry Date Date & Place of Issuance Expiry Date

Restriction Age Gender Relation To Insured/ Owner Restriction Code Age Gender Relation To Owner
Code
Owner’s Name Owner’s Name

Address Address

Government Issued ID & Date & Place of Issuance Government Issued ID & Date & Place of Issuance
No. No.
Contact Person Tel. No. Contact Person Tel. No.

Insured Vehicle Data Third Party Vehicle Data

Year/Make & Model/Color Plate No. Year/Make & Plate No.
Model/Color
Orig. 1st Owner Acquired From Orig. 1st Owner Acquired From
Purchase Purchase
2nd Owner, 3rd Owner, etc. 2nd Owner, 3rd Owner, etc.
Date: Date:
Motor No. Chassis No. Insurance Coverage CTPL
Company Comprehensive
Mortgagee/ Financing
Both
Vehicle Use: Private Business ____ Policy No. Coverage Period
For Hire Others ______
Shade Damaged Portions Sketch of the Accident-please indicate roads and Shade Damaged Portions
landmarks

Exact Place of the Incident: Exact Date of the Incident: Exact Time of the Incident: Estimated Vehicle Speed:
AM PM
Point of Origin Point of Destination Purpose of Travel

Narration: (Please state the origin and destination and the reason for the journey, and other relevant information.)

NOTE: Please submit Photos/ video taken at the time or immediately after the incident documenting the vehicle impact and resting position of the vehicle
Is the vehicle immovable? If immovable- current location of the vehicle If already taken out from the accident site, who facilitated the pull-out/towing?
YES NO
The vehicle was towed/pulled-out by: Paid Service Provider Covered by Roadside Assistance Program (RAP) Others, please specify______________________
If towed by a Paid Service Provider, please provide towing receipt.

___________________________________ ____________ _____________________________ ___________

Signature over printed name Date Signature over printed name Date
Insured/Authorized Driver of Insured Unit Standard Insurance Authorized Personnel
(Affiant) (if present during completion of this form)
 MOTOR ACCIDENT REPORT FORM (Page 2 of 2)
(to be completed fully and returned immediately)
Assured’s Name Policy No.

Address Conduction Sticker No./Plate No. Nature of Loss

Email Address Tel. No./Mobile No. Insured Vehicle

Damage Caused by Whom? (Who was at Fault?): Insured Vehicle Third Party Vehicle (TP)
If Caused by the Third Party (TP) Name of TP Owner/Driver TP Address TP Contact No. TP Email Address
Vehicle:

Other TP information obtained Settlement/Agreement/Compromise entered into by the Parties, if any

Injured Persons (Please shade the diagram below showing injured part/s of the body)
NAME ADDRESS GENDER & AGE HOSPITAL BROUGHT TO

Brief description of the injuries sustained

Reminders
• Standard Insurance reserves the right to request additional documents during the processing of the claim.
• The issuance of this form is not an admission of liability on the part of the Insurer.
• Any omission may delay the processing of the claim.
• Do not proceed with repairs without Insurer’s permission.
Declaration
By signing this document, I confirm that the information provided above are true and correct and that I shall fully cooperate and comply with the
submission of supplemental documents or information that Standard Insurance may require in support of my claim under the subject Policy.

Accomplished by:

____________________________________ ____________ _____________________________ _____________

Signature over printed name Date Signature over printed name Date
Insured/Authorized Driver of Insured Unit Standard Insurance Authorized Personnel
(Affiant) (if present during completion of this form)

REPUBLIC OF THE PHILIPPINES )S.S.

CITY OF _____________________ )
x ------------------------------------------------- X

SUBSCRIBED AND SWORN to before me this ______ day of ______________________ in ______________________,

Philippines. Affiant exhibiting to me his/her ___________________________ as Competent Evidence of Identity,
issued on _______________ and valid until ____________________.

Notary Public
Doc. No. ______________;
Page No. ______________;
Book No. ______________;
Series of ______________.

CLM 016
Rev. 2
02/27/2023