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Accident Information Form
(Print this form and keep it in your glovebox in case of an accident)
Date Time
Location City
Driving Direction
Near/at intersection of:
Lights: On / Off Weather:
Other drivers information:
Name:
Address
Phone Numbers
License #
Make of car Plate #
Witness Information:
Name Phone #
Name Phone #
Name Phone #
Officer Name Badge #
Describe any details below:
_______________________________________________________________________________
_______________________________________________________________________________
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Art Moehn Collision Center
2200 Seymour Rd.
Jackson, MI 49201
517-787-7700
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