Vehicle Accident / Incident Report Form

Remain calm
Call your supervisor or the office IMMEDIATELY from the site of the accident.
Complete this form as soon as possible, at the scene if possible, and turn in to your supervisor.
Your supervisor will take care of reporting to their insurance center.
If safe to leave vehicles in traffic, do not move vehicles until told to do so by Police.
Call police to investigate accident.

Date:

Time of Accident:

Location of Accident

Street address, City

INSURED'S VEHICLE

Driver's name:

Driver's License Number:

Driver's Address:

Vehicle Make and Model:

Vehicle License Number:

OTHER VEHICLE INFORMATION

Driver's Name:

Driver's License Number:

Driver's Address:

Driver's Date of Birth (mm/dd/yyyy):

Number of People in the Vehicle:

Owner of Vehicle:

Owner's Address:

Vehicle Make and Model:

Year:

Color:

Vehicle Serial Number:

Plate #:

State of Registration:

Insurance Company:

Proof of Insurance in Vehicle:

Policy Number:

Name & Phone Number of Agent:

WITNESSES

Witness #1 Name:

Witness #1 Address:

Witness #1 Phone Number:

Witness #2 Name:

Witness #2 Address:

Witness #2 Phone Number:

ACCIDENT

Direction your car was going:

Speed of insured's vehicle:

Direction of other car:

Approximate speed of other car:

Did you give warning signal?

What kind of signal?

Were your lights on?

Did the other driver signal?

What kind of signal?

Were his/her lights on?

Weather at the time of accident:

Condition of road at time of accident:

What was the posted speed limit?

Were all persons in insured's vehicle wearing seat belts?

Were all persons in other vehicle wearing seat belts?

Did Police make report of accident?

City, County or State Police?

Insured's description of accident:

Date of Report: