Form Da 2041 - Accident Report Louisiana State Driver Safety Program
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1DA 2041
Rev. 12/98
ACCIDENT REPORT
LOUISIANA STATE DRIVER SAFETY PROGRAM
Submit report to ORM
within 48 hours of accident
SUPERVISOR
1. Agency Name
2. Person to Contact
3. Phone
4. Loc. Code
TO COMPLETE
FIRST 4 ITEMS
5. State Vehicle Driver’s Name
6. Personnel Number
7. Date of Accident
8. Time of Accident
AM
PM
9. Exact Location of Accident (Use street markers, mileage markers, etc., to pinpoint location)
10.
DESCRIBE
HOW ACC.
HAPPENED
11.Seat Belt in Use
Yes
No
STATE VEHICLE INFORMATION
If other then vehicle damage, fill in as much as possible under “Other Vehicle” section substituting property owner information for vehicle driver.
12. State Vehicle Driver’s Address (Street No)
City
State
Zip Code
13. Home Phone
14. Work Phone
15. Driver’s License No.
16. Age
17. Sex
18. Vehicle’s Owner’s Name and Address
M
F
19. Year Vehicle
20. Make Vehicle
21. Model Vehicle
22. Body Type
23. Vehicle Lic. No. / Equip No. / VIN
24A. Where can the Vehicle be Seen ?
24B. Describe Damage
OTHER VEHICLE INFORMATION
If more than one vehicle is involved, submit additional sheet with information on other vehicle(s).
25. Other Vehicle Driver’s Name
26. Driver’s Social Security No.
27. Driver’s License No.
28. Age
29. Sex
--no longer required--
M
F
30. Other Vehicle Driver’s Address (Street No.)
City
State
Zip Code
31. Home Phone
32. Work Phone
33. Vehicle Owner’s Name and Address (Street No.)
City
State
Zip Code
34. Year Vehicle
35. Make Vehicle
36. Model Vehicle
37. Body Type
38. Vehicle I.D. No. or Lic. No.
39. Where can the vehicle be seen ?
40. Other Vehicle Insurance Co.
41. Policy No.
42. Describe Damage
43.Estimated Amount
$
INJURED
44. Name and Address
45. Phone
46.
47.
48.
49. Police Investigated ?
PED
Ins. Veh.
Other Veh.
Yes
No
44. Name and Address
45. Phone
46.
47.
48.
49. Type Report
PED
Ins. Veh.
Other Veh.
State
Sheriff
City
44. Name and Address
45. Phone
46.
47.
48.
49. Report No. (Item No.)
PED
Ins. Veh.
Other Veh.
WITNESSES OR PASSENGERS
50. Name and Address
51.
52. Phone
53.
53.
53.
53. (Specify)
Witness
PED
Ins. Veh.
Other Veh.
Passenger
50. Name and Address
51.
52. Phone
53.
53.
53.
53. (Specify)
PED
Ins. Veh.
Other Veh.
Witness
Passenger
54. State Driver’s Signature
55. Name of Driver’s immediate Supervisor and Phone No.
Submit by Email
Print Form
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