Accident Information Form

Diagram How Your Accident Happened

Photographs to Take

❏ Overall scene - from 4 directions, both close and far

❏ Damage to other vehicle(s)

❏ Damage to your vehicle

❏ "Things" or Objects involved (such as debris on highway, skidmarks)

Your Vehicle

Make, model & year

Color

License No.

Your car was struck . . .

❏ In the rear

❏ In the right rear

❏ In the left rear

❏ On the driver's side

❏ On the passenger's side

❏ In the front

❏ In the left front

❏ In the right front

❏ Other (explain)

Where damaged

Describe the damage

Other Driver

Name

Address

Telephone

Work Telephone

Driver's License No.

Insurance Company

Policy Number

Agent name and telephone

Statement

❏ If more than 1 other driver, mark here and write the information on the back.

Other Vehicle(s)

Address

Telephone

Work Telephone

Make, model & year

Color

License No.

Where damaged

Describe the damage

❏ If more than 1 other vehicle, mark here and write the information on the back.

Witnesses

Address

Telephone

Work Telephone

Location (passenger, other driver, pedestrian)

Statement

❏ If additional witnesses, mark here and write information on the back.

Accident Facts

Time

Location

Weather was . . .

❏ Clear

❏ Cloudy

❏ Raining

❏ Snow

❏ Fog

❏ Windy

Visibility was ...

❏ Daylight

❏ Dawn

❏ Dusk

❏ Dark

Road conditions (any defects)

Road surface was . . .

❏ Dry

❏ Wet

❏ Snow

❏ Ice

❏ Mud

In the area of the crash, the road was . . .

❏ Straight

❏ Curved

In the area of the crash, the road grade was . . .

❏ Level

❏ Uphill

❏ Downhill

Traffic conditions were . . .

❏ Heavy

❏ Medium

❏ Light

❏ Other

You were ...

❏ The driver

❏ Front seat passenger

❏ Rear seat passenger

❏ Pedestrian

Check the things involved in your accident and explain

❏ Stopped vehicle

❏ Turning vehicle

❏ Traffic signs

❏ Traffic signal

❏ Alcohol

❏ Excessive speed

❏ Turn signals

❏ Turning vehicle

❏ Headlights

❏ Stoplights

❏ Skid marks

❏ Debris on road (what and where - make a picture)

❏ Pedestrians

❏ Parked car

❏ Cyclist

❏ Guardrail or light pole

❏ Fence or embankment

❏ Fixed object (wall, building, etc)

❏ Rollover

❏ Fire

❏ Intersection

❏ Ramp

Damage to Property Other than Vehicles

What property

Owner

Address

Telephone

Nature of damage

Your Injuries

Were you wearing a seatbelt? ❏ Yes ❏ No

Your airbag deployed and hit you. ❏ Yes ❏ No

You hit your head on the . . .

❏ Headrest

❏ Steering wheel

❏ Windshield

❏ Visor

❏ Roof

❏ Side window

Knocked unconscious ❏ Yes ❏ No ❏ Not sure

Describe where you have . . .

❏ Pain

❏ Numbness

❏ Tingling

❏ Burning

❏ Stiffness

❏ Bruises

❏ Bumps

❏ Scrapes

Injuries to Others

Name

Address

Telephone

Work Telephone

Type of injury

❏ If more than 1 other injured person, mark here and write the information on the back.

Police Information

Police Agency

Telephone

Report No.

Ticket issued

To whom

Ambulance Information

Telephone

Report No.

Towing Information

Address

Telephone

Where vehicle taken

Storage Facility Information

Address

Telephone