Car Accident Information FormStep 1 of 812%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 VehicleName*Phone*EmailMake, model & yearColorLicense 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 OtherOther DriverNameAddressTelephoneWork TelephoneDriver's License No.Insurance CompanyPolicy NumberAgent name and telephoneStatementOther Vehicle(s)OwnerAddressTelephoneWork TelephoneMake, model & yearColorLicense No.Where damagedDescribe the damageWitnessesNameAddressTelephoneWork TelephoneLocation (passenger, other driver, pedestrian)StatementAccident FactsDate MM slash DD slash YYYY Time : Hours Minutes AMPM AM/PMLocationWeather was . . . Clear Cloudy Raining Snow Fog WindyVisibility was ... Daylight Dawn Dusk DarkRoad conditions (any defects)Road surface was . . . Dry Wet Snow Ice MudIn the area of the crash, the road was . . . Straight CurvedIn the area of the crash, the road grade was . . . Level Uphill DownhillTraffic conditions were . . . Heavy Medium Light OtherYou were ... The driver Front seat passenger Rear seat passenger PedestrianCheck 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 RampDamage to Property Other than VehiclesWhat propertyOwnerAddressTelephoneNature of damageYour InjuriesAt the time of the collision . . .Were you wearing a seatbelt? Yes NoYour airbag deployed and hit you. Yes NoYou hit your head on the . . . Headrest Steering wheel Windshield Visor Roof Side windowKnocked unconscious Yes No Not sureDescribe where you have . . . Pain Numbness Tingling Burning Stiffness Bruises Bumps ScrapesInjuries to OthersNameAddressTelephoneWork TelephoneType of injuryPolice InformationOfficer's nameBadge numberLaw enforcement agencyTelephoneReport No.Ticket issuedTo whomAmbulance InformationAgencyTelephoneReport No.Towing InformationCompanyAddressTelephoneWhere vehicle takenStorage Facility InformationCompanyAddressTelephoneCAPTCHA