Personal Report Of Accident Form
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1
2PERSONAL REPORT OF ACCIDENT
This form should be completed when a traffic accident occurs and a law enforcement officer is not called to make a report. This
report is for your personal use and should not be mailed to the Department of Driver Services, as it will be destroyed upon
receipt.
INSTRUCTIONS:
1. Answer all questions to the best of your knowledge. If unable to answer any questions, mark “not known”.
2. Give exact time of accident (date, day and hour).
3. Under “Location of Accident” show sufficient information to locate exact scene of the accident.
4. Print or type all names and addresses.
5. Sign the report in the space provided on the reverse side.
6. Report must be complete as to exact names, birth dates, and drivers license numbers.
7. Use a second report form or a sheet of plain paper of the same size to report additional vehicles, injured persons, or witnesses, or
any other information for which there is insufficient space.
Time
DO NOT WRITE IN
Date of
Day of
THIS SPACE
Accident________
Week________ Hour______A.M.______P.M. Weather________________________________
(Clear, Raining, Fog, Etc.)
Place Where
L
City, Town
Accident Occurred:
County________________________ Or Township __________________________
O
If accident was outside city
_______ miles _______
{
}
limits indicate distance from
{
___________
" " " " " limits of
}
south-north
C
nearest town. Use two dis-
of
_______ miles _______
tances and two directions
" " " " " center of
City or Town
east-west
A
ry.
if necessa
ROAD ACCIDENT
OCURRED ON:______________________________________________________________________________________
T
Give name of street or highway number, (U.S. or State). If no highway number, identify by name.
I
" At its intersection with:
_______________________________________________________
Name of intersecting street or highway number
Check and
O
OR
_______ feet _______
_______________________________
complete one
{
}
south-north
show nearest intersecting street or high-
of
" Not at intersection:
way, house number, bridge, driveway or
_______ feet _______
N
other identifying landmark.
east-west
V
YOUR VEHICLE NUMBER 1
Vehicle
Approximate cost
E
_________________________________________________ License Plate _________________________________ to repair vehicle _______________
Year Make Type (sedan, truck, taxi, bus, etc.)
Year
State
Number
H
Driver________________________________________
________________________________________________________________________
Full Name
Street
City and State
I
Driver’s
Driver’s
Driver’s
Occupation____________________________________
License________________________
Birth Date__________________Age_____Sex_______
C
Carpenter, Sales Clerk, Etc.
State
Number
Mo.
Da
Yr
Owner_____________________________________________________________________________________Owner’s Birth Date_________________
L
Full Name
Street
City and State
Mo
Da
Yr
Parts of
Owner’s
Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________
E
" " " " " Yes
Is this vehicle covered by
State Number
IF YES TO EITHER SHOW
Name ________________________________________________________
" " " " " No
automobile liability insurance?
INSURANCE COMPANY
S
Show name of insurance company not name of insurance agency.
" " " " " Yes
If vehicle not covered, did driver
_______________________
" " " " " No
have liability policy applicable?
Show Policy Number Here
Address_______________________________________________________
OTHER VEHICLE NUMBER 2
Vehicle
Approximate cost
Space
_________________________________________________ License Plate _________________________________ to repair vehicle _______________
for
Year Make Type (sedan, truck, taxi, bus, etc.)
Year
State
Number
any
third
Driver________________________________________
_________________________________________________________________________
vehicle
Full Name
Street
City and State
on
Driver’s
Driver’s
Driver’s
reverse
Occupation____________________________________
License________________________
Birth Date__________________Age_____Sex_______
side.
Carpenter, Sales Clerk, Etc.
State
Number
Mo.
Da
Yr
Total
Owner_____________________________________________________________________________________Owner’s Birth Date_________________
vehicles
Full Name
Street
City and State
Mo
Da
Yr
involved
Parts of
Owner’s
Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________
State
Number
Is this vehicle or driver covered by automobile liability insurance? " Yes " No If Yes show name of Insurance Company_________________________
DAMAGE TO PROPERTY
Approximate
OTHER THAN VEHICLE___________________________________________________________________________
cost to repair $____________________
NAME OBJECT AND STATE NATURE OF DAMAGE
NAME AND ADDRESS OF OWNER OF DAMAGED PROPERTY________________________________________________________________________________
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