Bertie and Clinton Mutual Insurance Company

Accident Information Form

Important Information in the Case of an Automobile Accident:
If you get into an automobile accident, please obtain the following information from the other driver. The Niagara Regional Police are no longer providing accident information sheets.
Click here for a printable copy of the Accident Information Form.

Name and Address of the other Driver and Vehicle Owner
Telephone Number
Driver’s Licence Number
Year, Make and Model of other vehicle
Insurance Company and Policy Number of Other Vehicle
Agent/Broker Name

**Ask to see a Liability Certificate (pink slip) and Ownership for this information**
By getting this information at the scene, it could speed up the processing of your claim by as much as one month. Please contact our office if you have any questions.

Bertie and Clinton
1789 Merrittville Hwy., R.R. #2
Welland, Ontario Canada L3B 5N5
Tel: (905) 892-0606 Toll Free: (800) 263-0494 Fax: (905) 892-0365
E-mail: mail@bertieandclinton.com