Oklahoma Motor Vehicle Collision Report
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1
2D
P
S
EPARTMENT OF
UBLIC
AFETY
Submit Report if
O
M
V
C
R
KLAHOMA
OTOR
EHICLE
OLLISION
EPORT
Please Read
Settlement Has Not Been Made
Instructions on Reverse Side
Driver Compliance Division
PO Box 11415
3600 N. M L King Ave
Oklahoma City OK 73136-0415
Oklahoma City OK 73111
Collision Date
Time
No. of Vehicles
City
County
Involved
Collision Location
(Street Name or Highway Number, Nearest Intersection)
Driver Name
Owner Name
Same As Driver
VEHICLE NO. 1
(Your Vehicle)
Date
DL No.
DL State
Date of
DL No.
DL State
of Birth
Birth
Street
Street
Damage Estimate
City
State
Zip
City
State
Zip
Vehicle
Vehicle
Vehicle
Vehicle
Tag
Tag
Year
Make
Model
Tag No.
State
Year
Total Injury Amount::
YOU WILL BE CONSIDERED UNINSURED AND SUBJECT TO SUSPENSION OF YOUR DRIVER LICENSE IF THE FOLLOWING SECTION IS INCOMPLETE:
Insurance
Insurance
Phone
Company
Agent Name
Policy
Address
Number:
Policy Period
From
To
City
State
Zip
IMPORTANT: ATTACH ITEMIZED DOCTOR’/HOSPITAL/PHARMACY BILLS (ATTACH ADDITIONAL FORMS IF NECESSARY)
Name
Address
Age
Sex
Driver
Passenger
Pedestrian Injured Killed
Driver Name
Owner Name
VEHICLE NO. 2
Same As Driver
Date
DL
DL
Date
DL
DL
Other Driver/Owner
of Birth
Number
State
of Birth
Number
State
Street
Street
Date of Birth
City
State
Zip
City
State
Zip
must be
Code
Code
included
Vehicle
Vehicle
Vehicle
Vehicle
Tag
Tag
Make
Year
Type
Tag No.
State
Year
before action can be
taken under the
INSURANCE INFORMATION OF OTHER DRIVER:
INSURANCE DENIAL ATTACHED?
YES
NO
Financial
Responsibility Law
Insurance
Insurance
Phone
Company
Agent Name
Policy
Address
Number:
Policy Period
From
To
City
State
Zip
Driver Name
Owner Name
VEHICLE NO. 3
Same As Driver
Date
DL
DL
Date
DL
DL
Other Driver/Owner
of Birth
Number
State
of Birth
Number
State
Street
Street
City
State
Zip
City
State
Zip
Code
Code
Date of Birth
Vehicle
Vehicle
Vehicle
Vehicle
Tag
License
must be
Make
Year
Type
Tag No.
State
Year
included
INSURANCE INFORMATION OF OTHER DRIVER:
INSURANCE DENIAL ATTACHED?
YES
NO
before action can be
Insurance
Insurance
Phone
taken under the
Company
Agent Name
Financial
Responsibility Law
Policy
Address
Number:
Policy Period
From
To
City
State
Zip
Describe what you think caused the collision. Please refer to vehicles by number:
I AM:
Driver
Owner
Attorney/Corp./Agency Officer
Insurance Agent
I STATE THAT THE INFORMATION ON THIS REPORT IS TRUE
AND ACCURATE TO THE BEST OF MY KNOWLEDGE
Signature
Phone
Date
DPS FR307 024 012008
Print Form
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Parent category: Legal