[size=7.5000pt]事故时间
| [size=7.5000pt] [size=7.5000pt] [size=7.5000pt]年 月 日[size=7.5000pt] [size=7.5000pt] 时 分
| [size=7.5000pt]事故地点
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[size=7.5000pt]代码
| [size=7.5000pt]姓名
| [size=7.5000pt]驾驶证号或身份证号
| [size=7.5000pt]车辆牌号
| [size=7.5000pt]保险公司
| [size=7.5000pt]电话
| [size=7.5000pt]保险公司报案号
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[size=7.5000pt]A
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[size=7.5000pt]B
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[size=7.5000pt]C
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[size=7.5000pt]事故
[size=7.5000pt]情形
| [size=7.5000pt]1、追尾的 [size=7.5000pt]□
| [size=7.5000pt]2、逆行的 [size=7.5000pt]□
| [size=7.5000pt]3、倒车的 [size=7.5000pt]□
| [size=7.5000pt]4、溜车的 [size=7.5000pt]□
| [size=7.5000pt]5、开关车门的 [size=7.5000pt]□
| [size=7.5000pt]6、违反交通信号的 [size=7.5000pt]□
| [size=7.5000pt]7、未按规定让行的 [size=7.5000pt]□
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[size=7.5000pt]8、依法应负全部责任的其他情形 [size=7.5000pt]□
| [size=7.5000pt]情形描述:
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[size=7.5000pt]9、双方应负同等责任的 [size=7.5000pt]□
| [size=7.5000pt]情形描述:
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[size=7.5000pt]伤情及物损
[size=7.5000pt]情况
| [size=7.5000pt]
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[size=7.5000pt]当事人责任
| [size=7.5000pt]A方负本起事故
| [size=7.5000pt]B方负本起事故
| [size=7.5000pt]C方负本起事故
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[size=7.5000pt]1、全部责任 [size=7.5000pt]□
[size=7.5000pt]2、同等责任 [size=7.5000pt]□
[size=7.5000pt]3、无责任 [size=7.5000pt]□
| [size=7.5000pt]1、全部责任 [size=7.5000pt]□
[size=7.5000pt]2、同等责任 [size=7.5000pt]□
[size=7.5000pt]3、无责任 [size=7.5000pt]□
| [size=7.5000pt]1、全部责任 [size=7.5000pt]□
[size=7.5000pt]2、同等责任 [size=7.5000pt]□
[size=7.5000pt]3、无责任 [size=7.5000pt]□
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[size=7.5000pt]以上填写内容均为事实,如有不实,愿负法律责任。
[size=7.5000pt]
[size=7.5000pt]A签名:[size=7.5000pt] [size=7.5000pt] B签名:[size=7.5000pt] [size=7.5000pt] C签名:[size=7.5000pt]
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[size=7.5000pt]赔偿
[size=7.5000pt]情况
| [size=7.5000pt]自愿放弃保险索赔,自行解决协议如下:
[size=7.5000pt]
[size=7.5000pt]A签名:[size=7.5000pt] [size=7.5000pt] B签名:[size=7.5000pt] [size=7.5000pt] C签名:[size=7.5000pt]
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