Church Mutual Insurance Company

3000 Schuster Lane, P.O. Box 342, Merrill, WI 54452-0342

(715) 536-5577 • (800) 554-2642 • Fax (715) 539-4651
www.churchmutual.com
AUTOMOBILE ACCIDENT REPORT
Please furnish the following information for prompt handling of your claim.
You may call this information in to our office or you may fax or mail this form to us.

CLAIM INFORMATION
Date Reported 05-05-2020
Reported by: (Name) Charles Helen (Title) Charles Edward
(555) 123-4567
Phone: (Home) 9768336475 (Work) Engineer
Fax (555) 123-4568 E-mail [email protected]
Account No. 1234567890 Policy No. INS-1234567890 Effective Date 10-10-2020
Date of Loss 04-05-2020 Time of Loss 04:00am ❐ a.m. ❐ p.m.
Insured's Name (as it appears on policy) Greenfield Community Center
Address 1 (Street) 2429 S State ST
Address 2 (Street) 1630 Governer St
City Springfield State Illinois Zip Code 65619
ACCIDENT INFORMATION
Location of Accident (Street) 2501 Chatham Road
City Springfield State Illinois Zip Code 65618
Police Dept. reportedSpringfield police dept
to Springfield Officer’s Name/Badge No. Officer D. Martinez / #7853
Report No. SPR-25-0321 Violation issued None
Description of Accident - Describe fully - Detail on provided diagram
The insured’s vehicle was traveling east on Main St when another vehicle ran a red light at the intersection
with 4th Ave, colliding with the front passenger side. No serious injuries were reported at the scene. The
insured's vehicle sustained moderate damage to the front right side, including a broken headlight and
bumper damage.

WITNESSES
It is critical to give full name and address of every person who knows anything about the accident.
Name James Anderson Phone No.: Home (555)
93458604844 (555) 333-4444
111-2222 Work 9758533978
City Springfield State Illinois Zip Code IL 62704
Name Lisa Martinez (555) 555-6666 Work (555)
Phone No.: Home 9689473383 777-8888
9566375900
City Springfield State Illinois Zip Code IL 62705
Name David Brown Phone No.: Home 9567849738
(555) 999-0000 Work 9956784683
(555) 123-4567
City Springfield State IIIinois Zip Code IL 62706
Name Susan White 99568478454
(555) 222-3333 Work (555)
Phone No.: Home 9856748373 444-5555
City Springfield State IIIinois Zip Code IL 62707

CL 425 (10-99)
 INSURED’S VEHICLE AND DRIVER INFORMATION
Vehicle Serial No.1HGCM82633A123456
Year 2020 Honda
Make Model Accord
Vehicle No. on policy 2 License Plate No. SPR 875-XYZ State of Issue SPR
Are you insured with any other insurance company? ❐ No ❐ Yes If yes, what company? No
Name of Driver Michael R. Collins Phone No.: (Home) 9976847934
(555) 555-9874 (Work) 9567849003
(555) 555-4210
Relation to insured (employee, volunteer, family, etc.) Policyholder Date of Birth July 12, 1985 Age 39
Address (Street) 2650 Oakwood Ave
City Springfield State IIIinois Zip Code IL 62709
Driver’s License No. SPR-9834675 Purpose of Use Commuting Used with Permission ❐ No ❐ Yes
Describe damage to insured vehicle
Front right fender dented, headlight broken, front bumper cracked.

Repair Estimate $320 Where can vehicle be seen? Near a shop When? 04-05-2020
PASSENGERS IN INSURED VEHICLE (USE ADDITIONAL PAPER IF NECESSARY)
Name Emily L. Sanders Age 37 Sex Mf
Parent/Guardian Louis Marton Phone No. 9567484499
(555) 555-9574 Work Engineer
Address 2501 Chatham Road
City Springfield State IIIinois Zip Code IL 62711
Injuries Minor bruising on left arm, no medical treatment required.

Name Kevin J. Roberts Age 35 Sex M

Parent/Guardian James Willams Phone No. (555)
9588943678
555-9374 Work Manager
Address 1028 South Grand Avenue
City Springfield State IIIinois Zip Code IL 62712
Injuries Minor bruising on right arm, no medical treatment required.

Name Rachel B. Anderson 42Age SexM

Parent/Guardian Barron Hastings 9567894789
Phone No. (555) 555-9345 Work Shop keeper
Address 2720 fillmore street
City Springfield State IIIinois Zip Code IL 62713
Injuries Minor bruising on right leg, no medical treatment required.
PROPERTY DAMAGE TO OTHERS
Owner of Property/Vehicle David P. Foster Address 2022 dial court
City Springfield State IIIinois Zip Code IL 62714
Name of Driver David Horn 9567845673
Phone No. (Home) (555) 555-9393 (Work) Driver
Address (Street) 1650 Wabash Ave
City Springfield State IIIinois Zip Code IL 62717
Describe damage to insured vehicle
Driver’s side rear door and quarter panel dented. Scratches along rear bumper.

CL 425 (10-99)