| Name | Description | Type | Additional information |
|---|---|---|---|
| Name of Individual | string |
None. |
|
| Insurance Company | string |
None. |
|
| Insurance Company Policy Number | string |
None. |
|
| Address | string |
None. |
|
| Phone Number | string |
None. |
|
| Names of all passengers involved in vehicle | string |
None. |
|
| Additional Comments / Notes | string |
None. |