The Cincinnati Insurance Companies
AUTO REPORT
Keep this form handy. In the event of an auto
accident, you can use it to document incident
details for company records and potential
investigative needs. Submit the completed form
to your supervisor as soon as safely possible.
What to do at the scene of the incident:
• When conditions or regulations permit, move
onto shoulder or side of roadway to prevent
further damage and hazards. Place warning
signals or signs promptly.
• Contact the police, or ask someone else to do
this if youcannot.
• Summon medical assistance if anyone is
injured. Repeat call after five minutes if no
help arrives.
• Do not administer first aid, unless you are
qualified to do so.
• Keep calm, be courteous and don’t argue.
• Make no statement concerning the accident to
anyone except a police ocer. When possible,
get the ocer’s name, department, badge
number and incident report number.
• Do not accept responsibility or apologize
for anything.
• Obtain the names, phone numbers, addresses
and vehicle license plate numbers of witnesses
when possible.
• Obtain the names and addresses of all persons
involved in the accident.
• Before leaving the accident scene, make sure
you have all the facts.
• Take pictures of the accident scene, vehicle
damage and any other property damage if
you have a camera and you are able to do
sosafely.
You may report claims by contacting your
local agency or by calling Cincinnati
Insurance directly, 877-242-2544, and
providing claims-related information.
Insured Driver
Name
Address
City         State   ZIP
Date of Birth
Home Tel. No.     -   -
Work Phone No. - -
Email
Insured Vehicle
Vehicle License No.
Make        Type     Year
Vehicle No.
The Accident
Date            Hour
Location: City/Street/Route/State
Weather
Condition of Roadway
Any Dashboard Cameras? Y N
In Which Vehicles?
Any GPS/Tracking Devices? Y N
In Which Vehicles?
Did Airbags Deploy? Y N
In Which Vehicle?
Police Dept.
Police Ocer Name
Badge No.
Describe How Accident Occurred
Draw A Diagram
Show names of highways, points of compass
(N.E.S.W.) and direction of vehicles involved.
Describe Damage to Other Vehicle or Property
Damage to Property of Others
Other Driver’s Name
Address
City           State   ZIP
Home Tel. No.     -   -
Work Phone No. - -
Email
Other Vehicle Owner’s Name (If dierent than
driver)
Address
City           State   ZIP
Tel. No.     -   -
Vehicle License Plate No.
Make      Type       Year
Other Driver’s Insurance Co.
Policy No.
Passengers in Other Vehicle
Name
Address
City           State   ZIP
Tel. No.     -   -
Name
Address
City           State   ZIP
Tel. No.     -   -
Name
Address
City           State   ZIP
Tel. No.     -   -
Name
Address
City           State   ZIP
Tel. No.     -   -
Name
Address
City           State   ZIP
Tel. No.     -   -
Designate your car thus:
Other vehicle:
Passengers in Other Vehicle
Name
Address
City          State   ZIP
Tel. No. - -
Name
Address
City          State   ZIP
Tel. No. - -
Name
Address
City          State   ZIP
Tel. No. - -
Name
Address
City          State   ZIP
Tel. No. - -
Name
Address
City          State   ZIP
Tel. No. - -
Witnesses
Name
Address
City          State   ZIP
Home Tel. No.     -   -
Work Phone No.    -   -
Name
Address
City          State   ZIP
Home Tel. No.     -   -
Work Phone No.    -   -
Name
Address
City          State   ZIP
Home Tel. No.     -   -
Work Phone No.    -   -
For information, coverage availability in your state, quotes or policy service,
please contact your local independent agent recommending coverage. This
is not a policy. For a complete statement of the coverages and exclusions,
please see the policy contract. “The Cincinnati Insurance Companies”,
“Cincinnati Insurance” and “Cincinnati” refer to member companies of
the insurer group providing property and casualty coverages through The
Cincinnati Insurance Company or one of its wholly owned subsidiaries –
The Cincinnati Indemnity Company or The Cincinnati Casualty Company.
Each insurer has sole nancial responsibility for its own products. Not all
subsidiaries operate in all states. Do not reproduce or post online, in whole
or in part, without written permission. © 2021 The Cincinnati Insurance
Company. 6200 S. Gilmore Road, Faireld, OH 45014-5141.
Additional Notes
Signature of Driver
Name
Signature
Date
LC-121 (11/21)
STAY SAFE, RECORD
DETAILS, REPORT LOSS
Responding After an Auto Accident
cinfin.com
For information, coverage availability in
your state, quotes or policy service, please
contact your local independent agent
recommending coverage.
Our loss control service is advisory only. We assume no responsibility
for management or control of customer loss control activities or for
implementation of recommended corrective measures. These materials
were gathered from trade services and public information. We have not
tried to identify all exposures. We do not warrant that this information is
consistent with Cincinnati underwriting guidelines or with any federal, state
or local law, regulation or ordinance.
THE CINCINNATI ADVANTAGE: RISK MANAGEMENT SOLUTIONS LOSS CONTROL
THE CINCINNATI ADVANTAGE: RISK MANAGEMENT SOLUTIONS LOSS CONTROL