If you've been in a car accident, it's important to gather up all the relevant details -- how the accident happened, who was involved, who witnessed the crash, etc. To make sure you've collected all necessary information related to your car accident (and that the data is all in one place), print this form out and write your answers in the space provided. You may even want to carry a blank copy of this form in your glove compartment.
Click the image to the left to download and print.
Take photos of:
Your Vehicle
Owner
Make, model & year
Color
License No.
Your car was struck:
Other Driver
Name
Address
Telephone
Driver's License No.
Insurance Company
Policy Number
Agent name and telephone
Statement
Make sure to collect everyone’s information who was involved.
Other Vehicle(s)
Owner
Address
Telephone
Make, model & year
Color
License No.
Where damaged
Describe the damage
Witnesses
Name
Address
Telephone
Statement
Accident Facts
Date
Time
Location
Weather was:
Visibility was:
Road surface was:
In area of the crash, the road was:
In area of the crash, the road grade was:
Traffic conditions were:
Other
You were:
Check the things involved in your accident and explain
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?
Your airbag deployed and hit you.
You hit your head on the:
Knocked unconscious
Describe where you have:
Injuries to Others
Name
Address
Telephone
Type of injury
Police Information
Officer's name
Badge number
Law enforcement agency
Telephone
Report No.
Ticket issued
Ambulance Information
Agency
Telephone
Report No.
Towing Information
Company
Address
Telephone
Where vehicle taken
Storage Facility Information
Company
Address
Telephone
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