Auto Accident Report Form
ADVERTISEMENT
1
2
3
4IMPORTANT: Must be completed in Acrobat Reader.
IMPORTANT: Must be completed in Acrobat Reader.
Download Reader here
Risk Management | EGS
E-mail:
risk.management@oregon.gov
PO Box 12009
Website:
State of Oregon: Risk Management
Salem, OR 97309-0009
Find this form on the Web at:
503-373-7475
503-373-7337 fax
OREGON AUTO ACCIDENT REPORT FORM
Name
Age
Phone
Alternate Phone ________________________
Address
City
State
Zip
Driver’s License Number
State of Issue
Vehicle Plate #
Year
Make
Model
Owner
Res. Phone
Bus. Phone
Address
City
State
Zip
For what purpose was car being used at time of accident?
Has damage been repaired?
Yes
No
If yes, by whom?
If not, estimated cost to repair
By whom?
(estimates required; see pg 2 for more information)
Is car insured?
Yes
No
If yes, company name and policy number
Year
Make
Model
Vehicle Plate #
State Agency
Address
State Driver
Bus. Phone
Address
City
State
Zip
Date
Time
a.m.
p.m.
Who investigated?
Who was cited and why?
Describe Incident:
Police Report Number:
City/Nearest City
State
Location (mile post, exit number, cross streets, name of highway)
Name
Address
Phone
Car (state vehicle, other)
1.
2.
3.
Was anyone injured or complained of being hurt?
Yes
No
Name
Address
Phone
Age
Car
Nature of injuries
1.
2.
3.
Page 1 of 4
Revised 3/16/2016
Form No. DAS-RM Accident Form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business