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Besten's Auto Body & Collision Center
deals with collision repair and insurance companies everyday. Let us take care of all the
details and put your mind at ease.
Please print out this form for your glove box.
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570-282-7140 www.bestensautobody.com
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Date of Accident
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Time of Accident
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Other Driver's Name
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Address
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City, State
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Zip
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Home Phone, Cell Phone
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Year, Make, Model of Vehicle
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License #
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Drivers License # with State
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Insurance Company
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Agent
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Policy #
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Witness 1
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Witness 2
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Name
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Name
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Address
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Address
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City, State
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City, State
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Zip
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Zip
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Phone
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Phone
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Call us if you have
any questions
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570-282-7140
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