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Accident Report Form- DL state only field
This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Step One
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2.
Step Two
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3.
Step Three
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Step One
Please read the following information prior to filling out this form.
NOTE: All form information is submitted securely over an encrypted connection. If you choose to send a copy of the submitted information to yourself when submitting this form, please remember that e-mail is insecure and your private information could be intercepted by unauthorized recipients. By selecting the option to send a copy of this form to your email, you agree to accept all responsibility and liability if that information is compromised.
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Step Two
Printable Version
Accident Report Form
You must fill out all required fields that are marked with an asterisk (*).
Contact information for at least one vehicle driver/owner, to include full name, date of birth, address and phone number, must be included, or the report cannot be entered and will be discarded.
Please note for simplicity, the street on which the accident occurred will be referred to as "Street 1", and the nearest cross-street to the accident will be referred to as "Street 2". If the accident occurred in a parking lot, use the parking lot name in place of the street name. (Example: Shopko Parking Lot)
Time and Location
Date of Accident
*
Date of Accident
Day of Week
*
-- Select One --
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time of Accident
*
Time of Accident
Did the accident occur on private property?
*
Yes
No
Street/Parking lot on which accident occured?
*
Nearest cross-street to accident
*
Railroad Crossing number
Interstate Interchange number or mile-post
Number of vehicles involved
*
-- Select One --
1
2
3
more than 3
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Step Three
Information on vehicle #1
Number of people in vehicle # 1
*
-- Select One --
0 *for parked vehicle*
1
2
3
more than 3
If this vehicle was unoccupied, enter 0, but you must still include registered owner/victim information in the driver fields, for the report to be entered
.
Issuing State for Driver's License
*
First Name
*
Middle Initial
*
Last Name
*
Driver's Phone
*
Date of Birth
*
Date of Birth
Address
*
City
*
State
*
Zip Code
*
Passenger's names, address and phone number
Seat Belt Use
Yes
No
N/A *for parked vehicle*
Shoulder Belt Use
Yes
No
N/A *for parked vehicle*
Insurance Company
*
Policy Number
*
Vehicle License #
*
License State
*
License Year
*
Vehicle Year
*
Vehicle Make
*
Vehicle Model
*
VIN Number
*
Body Type
*
-- Select One --
2 door
4 door
Pickup
SUV
Van
Tractor
Trailer
Vehicle Color
*
Direction of travel or facing if parked
*
-- Select One --
North
South
East
West
Vehicle traveling or parked on
*
-- Select One --
Street 1
Street 2
Estimated Damage to Vehicle # 1
*
Information on vehicle # 2
Completely fill out driver and vehicle information. If this was a hit and run vehicle, enter "UNK" into all of the fields, and enter 01/01/01 for DOB.
Number of people in vehicle # 2
*
-- Select One --
1
2
3
more than 3
Unknown
Driver's License State
*
First Name
*
Middle Initial
*
Last Name
*
Driver's Phone
*
Date of Birth
*
Date of Birth
Address
*
City
*
State
*
Zip Code
*
Passenger's names, address and phone number
Seat Belt Use
*
Yes
No
Unknown
Shoulder Belt Use
*
Yes
No
Unknown
Insurance Company
*
Policy Number
*
Enter "UNK" in text fields if this is a hit and run report
Vehicle License #
*
License State
*
License Year
*
Vehicle Year
*
Vehicle Make
*
Vehicle Model
*
VIN Number
*
Body Type
*
-- Select One --
2 Door
4 Door
Pickup
SUV
Van
Tractor
Trailer
Unknown
Vehicle Color
*
Direction of travel or facing if parked
*
-- Select One --
North
South
East
West
Unknown
Vehicle traveling or parked on
*
-- Select One --
Street 1
Street 2
Estimated Damage to Vehicle # 2
*
Other Property Damage
List other property
Property Owner
Owner's address
City
State
Zip Code
Estimated Damage
Description of Accident
Please explain in your own words what transpired leading up to, during, and after the accident. Be as factual and complete as possible. if there were more than 2 vehicles involved, include additional vehicle/driver/passenger information in the narrative.
Description of Accident
*
Email Address of Party Filing Report
*
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
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