Vehicle Accident / Incident Report Form Page 2
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2VEHICLE ACCIDENT / INCIDENT REPORT FORM
ACCIDENT
__________________________________________________________________________________
Direction your car was traveling
__________________________________________________________________________________
Speed of insured’s vehicle
__________________________________________________________________________________
Were your lights on?
__________________________________________________________________________________
Did the other driver signal?
__________________________________________________________________________________
What kind of signal?
__________________________________________________________________________________
Were his/her lights on?
__________________________________________________________________________________
Weather at the time of accident
__________________________________________________________________________________
Condition of the road at time of accident
__________________________________________________________________________________
Was the speed limit posted? What was it?
__________________________________________________________________________________
Were all persons in insured’s vehicle wearing seat belts?
__________________________________________________________________________________
Were all persons in other vehicle wearing seat belts?
__________________________________________________________________________________
Did Police make report of accident?
City, State, or County Police
Insured’s description of accident:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
____________________
__________________________________________
Date of Report
Signature of Insured’s Driver
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Parent category: Business