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Accident Information FormDescribe 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 TakeMake 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 VehicleOwnerMake, 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 Where damaged Describe the damage
Other DriverNameAddress 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)OwnerAddress 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.
WitnessesNameAddress Telephone Work Telephone Location (passenger, other driver, pedestrian) Statement If additional witnesses, mark here and write information on the back. Accident FactsDateTime 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 InjuriesAt 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 OthersNameAddress Telephone Work Telephone Type of injury If more than 1 other injured person, mark here and write the information on the back. Police InformationOfficer's namePolice Agency Telephone Report No. Ticket issued To whom
Ambulance InformationAgencyTelephone Report No.
Towing InformationCompanyAddress Telephone Where vehicle taken Storage Facility InformationCompanyAddress Telephone
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