Accident Information Form

Name____________________________________________

Street address __________________________________

City________________ State _______ Zip ____________

Vehicle registration/ year/license number ____________

Make/model of car ___________________ Year_______

Does driver appear to have been drinking? ____________

Any statement made by other driver as to cause of accident:

______________________________________________

_________________________________________________

Passengers in Other Car:

Name__________________________________________

Address________________________________________

Name _________________________________________

Address________________________________________

All Possible Witnesses to Any Fact:

Name__________________________________________

Address________________________________________

Name _________________________________________

Address________________________________________

Conditions Noted Immediately after the Accident:

Position of your car after accident ___________________

________________________________________________

Position of other car after accident __________________

_________________________________________________

Location of any tire marks, blood, broken glass, dirt, etc. on road

or side of road ______________________________

_________________________________________________

Location of point of impact in relation to center of road or some physical object

_____________________________

Did your car skid? ______ If so, how many feet? _______

Did other car skid?______ If so, how many feet?

The following should be filled out at the scene or shortly after leaving the scene.

Date of accident _______________ Time _________

Location of accident __________________________

Type of road (grade, curve, etc.)__________________

Speed of your car just before accident ____________

Speed of other car just before accident ____________

Direction of your car __________________________

Direction of other car _________________________

Were you turning? ____________________________

Was other driver turning? ______________________

Did the other driver signal properly (with arm, horn, lights, etc.)?

_________________________________

If at night, were other vehicle’s lights on? __________

How far away from you was the other car when you first saw it?

______________________________________

Other pertinent facts _____________________________________