Auto Reporting Form Date of Accident: Address of Accident : Staff Name Reporting Accident: Contact Phone Number: Description of Accident: INSURED VEHICLE YEAR-MAKE-MODEL-LAST 5 OF VIN: Location of Insured Vehicle: Insured Driver (Name, Address, Phone): Passengers (Name, Address, Phone): Was Anyone Injured:YesNo IV Drivable: YesNo PROPERTY DAMAGE YEAR-MAKE-MODEL-LAST 5 OF VIN: Location of Insured Vehicle: Claimant Driver (Name, Address, Phone): Passengers (Name, Address, Phone): Was Anyone Injured: YesNo IV Drivable: YesNo Police Called (Department, Case Number): Photos Obtained? Additional Information: Privacy Policy Confirmation I agree to be contacted by Alera Group in accordance to their Privacy Policy as described below. By submitting this form, I agree I want to receive additional information from Alera Group, including by email, phone, and mail to the contact information I am submitting. I consent to Alera Group, its subsidiaries, and its service providers, processing my personal information for these purposes and as described in the Privacy Notice. I understand that I can withdraw my consent at any time. Δ Include a copy of driver exchange form Report within 24 hours