Form 735-32 - Oregon Traffic Accident And Insurance Report Page 3
ADVERTISEMENT
1
2
3
4
5
6
7OREGON TRAFFIC ACCIDENT AND INSURANCE REPORT
COMPLETE BOTH SIDES
Complete this form ONLY if your accident happened on a highway or premises open to the public, and resulted in any of the following: 1)
More than $2500 in damage to your vehicle; 2) More than $2500 in damage to any one person's property other than a vehicle; 3) Any vehicle
has more than $2500 and any vehicle is towed from the scene as a result of damages; 4) Injury to any person (no matter how minor the
injury); or, 5) the death of any person.
DO NOT WRITE IN
DAY OF WEEK
TIME OF DAY
ACCIDENT DATE
COUNTY
Accident
M T W TH F
AM
THIS SPACE
Number
S SN
PM
MILE POST
TYPE OF ACCIDENT - The accident involved one or more of the following: (Mark all that apply)
ROAD ON WHICH ACCIDENT OCCURRED (Name of street, road or route )
Two vehicles
ATV / Snowmobile
Parked vehicle
More than two vehicles
Motorcycle
Overturned vehicle
NAME OF NEAREST INTERSECTING ROAD
WITHIN
FEET
N S
E W
NEAR
MILES
N S
E W
Fatality
Motorized Scooter
Animal
Personal (assisted)
Bicycle
NAME OF NEAREST CITY / TOWN
Fixed object / property
WITHIN
FEET
N S
E W
mobility device
NEAR
MILES
N S
E W
Pedestrian
Train
Other ____________________
Complete ALL of this section. If you fail to do so, your driving privileges may be suspended. You MUST list the insurance company (not
agent) and policy number that provided liability coverage for the vehicle you were driving.
DRIVER’S NAME (LAST, FIRST, MIDDLE)
DRIVER’S LICENSE NUMBER
STATE
DATE OF BIRTH
SEX (CIRCLE)
M
F X
DRIVER’S RESIDENCE ADDRESS
CITY
STATE
ZIP CODE
CHECK BOX
IF ADDRESS
CHANGE
MAILING ADDRESS (IF DIFFERENT THAN RESIDENCE)
CITY
STATE
ZIP CODE
VEHICLE OWNER’S NAME AND ADDRESS
CITY
STATE
ZIP CODE
SAME
INSURANCE COMPANY NAME (NOT AGENT) AND ADDRESS
CITY
STATE
ZIP CODE
POLICY NUMBER
VEHICLE IDENTIFICATION NUMBER
VEHICLE PLATE NUMBER
STATE
YEAR
MAKE & MODEL
Check all
Damage to your vehicle was more than $2500.
statements
Damage to any one person’s property (other than vehicle) was more than $2500.
that apply:
Your vehicle was towed from the scene as a result of damages.
You or passengers in your vehicle were injured.
The accident occurred while you were driving your employer’s vehicle.
You were driving on your job and being paid for the principal purpose of driving.
You were being paid to drive and/or deliver persons or property.
You were operating a government owned vehicle marked for transporting mail in accordance with government rules.
You were operating an authorized emergency vehicle.
You were operating a commercial motor vehicle requiring you to have a commercial driver license.
You were transporting hazardous material.
The accident occurred in a work or maintenance zone. ORS 811.230
A police officer came to the scene.
Name of police department: __________________________
City
County
State Police
A citation was issued to you. The citation was: ________________________________________________________
DRIVER’S NAME (LAST, FIRST, MIDDLE)
DRIVER’S LICENSE NUMBER
STATE
DATE OF BIRTH
SEX (CIRCLE)
M
F X
DRIVER’S ADDRESS
CITY
STATE
ZIP CODE
VEHICLE OWNER’S NAME AND ADDRESS
CITY
STATE
ZIP CODE
SAME
INSURANCE COMPANY NAME (NOT AGENT) AND ADDRESS
POLICY NUMBER
VEHICLE IDENTIFICATION NUMBER
VEHICLE PLATE NUMBER
STATE
YEAR
MAKE & MODEL
IF ADDITIONAL VEHICLES WERE INVOLVED IN THE ACCIDENT, USE ATTACHED SUPPLEMENTAL REPORT (Form 735-32B).
DESCRIBE WHAT HAPPENED: (IF MORE SPACE IS NEEDED, SUBMIT ADDITIONAL PAGE)
I certify all information given on this report is true and accurate to the best of my knowledge.
SIGNATURE OF PERSON MAKING REPORT
PRINTED NAME OF PERSON MAKING REPORT
DAYTIME PHONE #
DATE SIGNED
(
)
X
REASON DRIVER IS UNABLE TO SIGN REPORT
PHONE NUMBER OF DRIVER
IF NOT DRIVER’S SIGNATURE, STATE RELATIONSHIP
(
)
COMPLETE THE OTHER SIDE OF THIS PAGE
STK# 300009
735-32 (1-18)
DMV COPY
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal