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Accident Information Form

Describe How Your Accident Happened











Diagram How Your Accident Happened

(Identify vehicles. Yours is 1 and others are 2, 3, 4 . . . Show direction of travel with arrows)









Photographs to Take

Make pictures of . . .

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

Owner

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)

Owner

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

Name

Address

Telephone

Work Telephone

Location (passenger, other driver, pedestrian)

Statement

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

Accident Facts

Date

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

(such as parked car, mailbox, fence, light pole, etc.)

What property

Owner

Address

Telephone

Nature of damage

Your Injuries

At the time of the collision . . .

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

Officer's name

Police Agency

Telephone

Report No.

Ticket issued

To whom

Ambulance Information

Agency

Telephone

Report No.

Towing Information

Company

Address

Telephone

Where vehicle taken

Storage Facility Information

Company

Address

Telephone



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