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.

Car Accident Information Form

Take photos of:

• Overall scene - from different angles; close up and far away
• Damage to other vehicle(s)
• Damage to your vehicle
• "Things" or objects involved (such as debris on highway, skid marks)

Your Vehicle
Owner
Make, model & year
Color
License No.
Your car was struck:

• In the rear: Left or right?
• Driver's Side
• Passenger side
• Front: Left or right?
• Other

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:

• Clear
• Cloudy
• Raining
• Snow
• Fog
• Windy

Visibility was:

• Daylight
• Dawn
• Dusk
• Dark

Road surface was:

• Dry
• Wet
• Snow
• Ice
• Mud

In area of the crash, the road was:

• Straight
• Curved

In area of the crash, the road grade was:

• Level
• Uphill
• Downhill

Traffic conditions were:

• Heavy
• Light
• Medium
• Other

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

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
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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