Vehicle Accident / Incident Report Form
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2VEHICLE ACCIDENT / INCIDENT REPORT FORM
Remain calm
Call your supervisor or the office IMMEDIATELY from the site of the accident.
Complete this form as soon as possible, at the scene if possible, and turn in to your supervisor.
Your supervisor will take care of reporting to their insurance center.
If safe to leave vehicles in traffic, do not move vehicles until told to do so by Police.
Call police to investigate accident.
______________________
____________________________________________
Date
Time of Accident
__________________________________________________________________________________
Location of Accident
__________________________________________________________________________________
(Street address, City)
INSURED’S VEHICLE
OTHER VEHICLE INFORMATION
_____________________________________
_________________________________________
Driver’s name
Driver’s Name
_____________________________________
_________________________________________
Driver’s Address
Driver’s Address
_____________________________________
_________________________________________
Driver’s License Number
Driver’s License Number
_____________________________________
_________________________________________
Vehicle Make and Model
Driver’s Date of Birth
_____________________________________
_________________________________________
Vehicle License Number
Number of People in the Vehicle
_________________________________________
WITNESSES (Over for additional space)
Owner of Vehicle
_____________________________________
_________________________________________
Name
Owner’s Address
_____________________________________
_________________________________________
Address
Vehicle Make
_____________________________________
_________________________________________
Phone Number
Model
Year
Color
_____________________________________
_________________________________________
Name
Vehicle Serial Number
_____________________________________
_________________________________________
Address
State of Registration
Plate #
_____________________________________
_________________________________________
Phone Number
Insurance Company
_________________________________________
Policy Number
_________________________________________
Name & Phone Number of Agent
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Parent category: Business