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❏ 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)
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
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.
❏ If more than 1 other vehicle, mark here and write the information on the back.
Location (passenger, other driver, pedestrian)
❏ If additional witnesses, mark here and write information on the back.
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
❏ 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
❏ 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
What property
Owner
Nature of damage
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
Type of injury
❏ If more than 1 other injured person, mark here and write the information on the back.
Police Agency
Report No.
Ticket issued
To whom
Where vehicle taken
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