Car Accident Information Form Step 1 of 8 12% Describe How Your Accident HappenedPhotographs to Take Take pictures of... Overall scene - from different angles; from close up and far away Damage to other vehicle(s) Damage to your vehicle "Things" or Objects involved (such as debris on highway, skidmarks) Your Vehicle Name* Phone*Email Make, model & year Color License No. Your car was struck . . . In the rear In the right rear In the left rear On the driver's side On the passenger's side In the front In the left front In the right front Other Other Driver Name Address TelephoneWork TelephoneDriver's License No. Insurance Company Policy Number Agent name and telephone Statement Other Vehicle(s) Owner Address TelephoneWork TelephoneMake, model & year Color License No. Where damaged Describe the damage Witnesses Name Address TelephoneWork TelephoneLocation (passenger, other driver, pedestrian) Statement Accident Facts Date MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Location Weather was . . . Clear Cloudy Raining Snow Fog Windy Visibility was ... Daylight Dawn Dusk Dark Road conditions (any defects) Road surface was . . . Dry Wet Snow Ice Mud In the area of the crash, the road was . . . Straight Curved In the area of the crash, the road grade was . . . Level Uphill Downhill Traffic conditions were . . . Heavy Medium Light 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 Turning vehicle Headlights Stoplights Skid marks Debris on road 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 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 TelephoneWork TelephoneType of injury Police Information Officer's name Badge numberLaw enforcement agency TelephoneReport No. Ticket issued To whom Ambulance Information Agency TelephoneReport No. Towing Information Company Address TelephoneWhere vehicle taken Storage Facility Information Company Address Telephone CAPTCHA Δ