Accident/incident Report (Page 2 of 2) in pdf

Accident/incident Report Page 2

DECLARATION OF AUTOMOBILE ACCIDENT FACTS

I, the undersigned declare under the penalty of perjury under the laws of State of California.

I witnessed the automobile accident described herein. If called to testify I can and will testify to the following accident facts:

Please draw in the diagram to your best knowledge:

What date and time did the accident and/or loss occurred?

AM/PM

Please list the intersection or the major cross street:

City of Accident:

What direction were you traveling?____________________________On what street?____________________What speed?_____

What direction was the other car traveling?______________________On what street?____________________What speed?_____

Was the road paved asphalt, cement, brick, dirt, or gravel?

Was the road wet or dry at the time of the accident?

Which police department came out to the scene of the accident?

What is the police report #:

Whom in your opinion, was at fault and why?

I, the undersigned declare under the penalty of perjury that the facts stated herein are true and correct.

Renter and/or Driver’s Signature:

Today’s Date:

Midway Rep:

Date:

REV:01/24/2013 M:Mrac_PublicClaimsACR FORMS2013 AUTO CLAIM REPORT

Accident/incident Report Page 2