WPC  N!YRѱxy$%=N0 b@kMMQ|Ґx7= 4MFd<rҫ<,s,˚R"%1R_失QQͶPgg8.' &dL_]h2u ]Wq{al$BwҌgg*2(SK_*ЊOME> F?<_`n VJ;QżDuvIT؋zojA^ a@ fT aV fj al f a  nO 0r g wg 4k  m \  `*Times New RomanTT'   'HUBBARD 2 $Lianne Snider0user .   h:Default ParaDefault Paragraph FontXXXW\  `*Times New RomanTTW        &&&W\  `*Times New RomanTTWTable_AK Kd2 `*Times New RomanTTTable_B dTable_CTable_DTable_ETable_FTable_GTable_HTable_I3|x\  `*Times New RomanTTC\  P6QP\  `*Times New RomanTT&&J\  P6Q&P\  `*Times New RomanTTXXP\  P6QXP2 `*Times New RomanTT` P7P2 `*Times New RomanTT^^T P7^P(J$&:%&:%%&:  ]{'$阂- U !&:%&:%%&:   ݛXXXX*q ddd Xdd Xdd XX%X%q,ZZ@+  3" X KKC3%&:  HUBBARD  K INSURANCEBROKERS5+)C KK  5  H4XX` hp x (#%XH PHONE:9057124668 s FAXTO:9057123586  AUTOMOBILEREPORTNOTICEOFACCIDENT  J   *O ddZZ@X%X%O,HZj@,pjZ@,ZZ@+  5 "  C5^V_ POLICY   HOLDER 7 *x  C3  C7_^VName:_______________________________________________________________________________   Address:______________________________________________________________________________ ; */  C  C;PolicyNo:_________________________________________BusinessPhoneNo:_________________________________ N =%7C    CN^V_ INSURED   VEHICLE,DRIVERANDUSE 9 * 2 C3  C9_^VTractorBus:Year_________Make:__________________SerialNo:______________________________   TrailerBus:Year_________Make:__________________SerialNo:______________________________OwnerofAboveTractor:________________________________________________________________WasequipmentbeingoperatedaboutbusinessofAssured:______________________________________NameofDriver:________________________________________________________________________Address:___________________________________________________________________________________________________________________________________________________________________Driver'sLicenceNo:____________________________________________________________________ 4* C  C4ТLic.No:_______________________Prov.:______________̢Lic.No:_______________________Prov.:______________Trailer:____________________________________________OtherInsuranceAvailable:______________________________________________________________________________PhoneNo:_________________________________________Age:______________________________________________No.ofHoursonDuty:_______________________________ :0 %C  C:^V_ CARGO W & LOSS , 8 'C3 C,_^VTypeoflossandcommodity:_____________________________________________________________ W ( ТPresentLocation:________________________________________________________________________ 7 *O )C  C7BillofLadingEnclosed:No___________Yes_________________ J =%,C    CJ^V_ DETAILS G-   OF  ACCIDENT 9 *Y/C3  C9_^VԀDate:____________________________19_________Time:____________________am/pm__________ G0 Place:________________________________________________________________________________PoliceReportMadeTo:________________________CityOfficersNumber_______________________AnyChargesLaid:_____________________________________________________________________WhatCharge:__________________________________________________________________________ 7 *g5C  C7ТWeatherConditions__________________________________ConditionsofRoad:__________________________________CityorTown:_______________________________________Province:__________________________________________̢AgainstWhom:______________________________________ P =%:C    CP  ^V_ DAMAGE o;   TO  VEHICLE  OFPOLICYHOLDER  7 *MAC2  C7_^V COLLISION:____________________FIRE:______________________THEFT:___________________  C PresentLocationofAssured'sVehicle?______________________________________________________̢AssuredsEstimateofDamage:___________________________________________________________CanAssuredCompleteRepairs?_____________WereTemporaryRepairsMade:____________________ 7 *,HC  C7 OTHER: __________________________________________ J Truck:____________Tractor:__________________________Trailer:____________Bus:____________________________Amount:__________________________________________ P =%/OC    CP^V_ DAMAGE  TO  PROPERTY  OFOTHERS ; *VC#  C;_^VOwnerofVehicle:______________________________________________________________________ W Address:______________________________________________________________________________LicenceNo:___________________________________________Phone___________________________Damage:______________________________________________________________________________InsuranceCompany:____________________________________________________________________OwnerofVehicle:______________________________________________________________________Address:______________________________________________________________________________LicenceNo:___________________________________________Phone___________________________Damage:______________________________________________________________________________InsuranceCompany:____________________________________________________________________ ; * aC  C;DriverofVehicle:___________________________________YearandMakeofVehicle:__________________________LicenceNo:________________________________________PolicyNo:_________________________________________Province:__________________________________________DriverofVehicle:___________________________________YearandMakeofVehicle:__________________________LicenceNo:________________________________________PolicyNo:_________________________________________Province:__________________________________________5+)'kC     5*q ddHZj@pjZ@ZZ@ X%X%q,HZj@, ZZ@, jZ@, jj@, ZZ@+  5 "  wk C5^V_ INJURED 4*!nC3  C4  _^V(1)  o   Name:____________________________________Address:___________________________________________________________________________Phone:____________________Age:___________Injuries:__________________________________Doctor:___________________________________Hospital:__________________________________  , %#wC  C,  (2)  Name:____________________________________Address:___________________________________________________________________________Phone:____________________Age:___________Injuries:__________________________________Doctor:___________________________________Hospital:__________________________________ = *%#C  C=  (3)  Name:____________________________________Address:___________________________________________________________________________Phone:____________________Age:___________Injuries:__________________________________Doctor:___________________________________Hospital:__________________________________ 4*%#C  C4( C  (  &'$ * ddHZj@ ZZ@ jZ@ jj@ ZZ@ X%X%, ZZ@,hZZ@,ZZ@+  ,"  C, OCCUPANTSOFINSUREDVEHICLE    '=C C' 'C C' :0C C:NAME:_______________________________________ '5C C'ADDRESS:_________________________________________________ '5C C'PHONE:________________ A 0} C CANAME:_______________________________________ ; *u C  C;ADDRESS:_________________________________________________ ; *u C  C;PHONE:________________ G=% C    CG OCCUPANTSOFOTHERVEHICLE:  e   'C C' 'mC C' :0mC C:NAME:_______________________________________ 'JC C'ADDRESS:_________________________________________________ 'JC C'PHONE:________________ :0B C C:NAME:_______________________________________ ' C C'ADDRESS:_________________________________________________ ' C C'PHONE:________________ :0 *C C:NAME:_______________________________________ '" C C'ADDRESS:_________________________________________________ '" C C'PHONE:________________ A 0 j C CANAME:_______________________________________ ; *b C  C;ADDRESS:_________________________________________________ ; *b C  C;PHONE:________________5+) "C     5*q dd ZZ@hZZ@ZZ@X%X%q, ZZ@,hZZ@,ZZ@+  ,"  Z " C, IMPORTANT:INDEPENDENTWITNESSES:(Includenamesofbystanderswhosawaccident,orheardanystatementsmade)  R $  ' %C C' ' Z &C C'( Z 'C (*q dd ZZ@hZZ@ZZ@X%X%q, ZZ@,hZZ@,ZZ@+  ," 7 ' C,NAME:_______________________________________ '7 (C C'ADDRESS:_________________________________________________ '7 )C C'PHONE:________________ :0/ +C C:NAME:_______________________________________ 'w,C C'ADDRESS:_________________________________________________ 'w-C C'PHONE:________________ A 0o/C CANAME:_______________________________________ ; *0C  C;ADDRESS:_________________________________________________ ; *1C  C;PHONE:________________5+)W3C     5*q dd ZZ@hZZ@ZZ@X%X%q,Zj@,hZj@,hZZ@+  5 " _3 C5 THEACCIDENT           = *M<C  C=POLICYHOLDER'SVEHICLE:SPEED:BeforeTheAccident:_______________________________km/hAtInstantofAccident:___________________________perhourLIGHTS:_____________________________________________̀(ONOFFDIMBRIGHT)WhichSideofRoad_______________Warning:_____________DirectionTravelled:____________________________________ ; *_EC  C;OTHERVEHICLE:SPEED:BeforeTheAccident:_______________________________km/hAtInstantofAccident:___________________________perhourLIGHTS:_____________________________________________̀(ONOFFDIMBRIGHT)WhichSideofRoad_______________Warning:_____________DirectionTravelled:____________________________________5+)_NC    5*q ddZj@hZj@hZZ@X%X%q,pZZ@,hZZ@,ZZ@+  3 " N C3 DRIVER'SSTATEMENTOFHOWACCIDENTOCCURRED:  O  ; *TPC  C; 4*QC  C4(RC  (*q ddpZZ@hZZ@ZZ@X%X%q,%jj@+  5 " \R C5 P =%lSC    CP P =%TC    CP P =%tUC    CP P =%|$VC    CP P =%,WC    CP P =%XC    CP P =%4YC    CP P =%<ZC    CP P =%[C    CP N =% D\C   CN G=%L!]C    CGWhatpartofyourvehicleandwhatpartofothercarwerefirstintouch?_____________________________________________________________________________ :0"D _C C:Whomdoyouconsiderisresponsible?_________________________________________________________________________________________________________ :0#!aC C:DateSigned:____________________________________________SignatureofDriver:__________________________________________________________________ :0%"cC C:DateReported:__________________HowReported:__________Phone:__________Wire:____________Letter:_________InPerson:_________Time:________________ Attachadiagramtofurtherexplainaccident,showpointsofcompass,nameofstreets,directionofcarsandpositionofcarsatinstantofaccident (&$fC  (&:%&:%%&:Ԝ