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Help where possible.Don't move injured. Listen to what others say. Do not give opinions. Do not apologize or admit fault.

Accident Date:_____/______/______   Posted Speed Limit:_____________________________________________________

Location:____________________________________________________________________________________________

Eye Witnesses Name                                         Address                                                               Phone

 

 

 

 

 

 

 

Accident Party Names                                       Address                                                              Phone

 

 

 

 

 

 

 

 

 

 

Ask Witnesses for business cards and home phone numbers. Do not talk about accident specifics with anyone at the scene except police.

Primary Police Officer Name & Badge #

City

HQ Phone & Notes

 

 

 

 

The police officer can give you instructions to obtain the report after it is submitted. Give FACTS only. No opinions. Admit no fault.

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Weather

Visibility

Road

Crash Area

District

 

c Clear

c Snow

c Sleet

c Rain

c Fog

c Mist

 

c

 

cSunny

cCloudy

cOvercast

cDusk

cDark Night

cMoonlight

cStreet Lights

c

 

cDry

cWet

cSlippery

cIce

cOil

cSand

 

c

 

cFlat

cConcrete

cAsphalt

cDirt

cStone

 

 

c

 

cCity

cBusiness

cResidential

cWooded

cOpen Field

 

 

c

 

cSpeed Sign

cStop Sign

cCaution Sign

cWork Area

cHospital Zone

cSchool Zone

 

c

Do not talk about the accident specifics with anyone at the scene except police. FACTS only. No opinions. Admit no fault.

Condition of Vehicle That Contacted Your Vehicle 

 

______My car hit _____My car was hit

Age and General condition of other vehicle

 

 

Safety Inspection _______________Mo/Yr

 

Take Pictures Of

c damage to all vehicles

c driving area especially skid marks

c your injuries and bruises afterwards

c On the back of this page, draw the streets and vehicles as they stopped. Use arrows to show movement direction.

Emergency Telephone Numbers

Family Doctor

 

Towing Service/Auto Club

 

Nearest Relative

 

Car Repair/Dealer

 

Attorney

 

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