Auto Accident Report Form Page 2
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4Risk 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
D I A G R A M
T H E
A C C I D E N T
S C E N E :
Right
Right
Please mark the
damaged areas on
the corresponding
vehicles.
Left
Left
State Car
Other car:
Check all that apply
Conditions:
Type of Incident:
Incident
Were there
What was your
If your vehicle was
How fast were you
driving?
(check one)
occurred on:
flashing lights
vehicle doing in
damaged from rocks or
or warning
relation to the
debris, where did they
signs?
other vehicle?
come from?
Passing
Daylight
Sanding
Straight road
Yes
Road surface
Your speed?
mph
Following
Vehicle tire
Dawn
Pothole
Curve
No
Parked
Load
Dusk
Resurfacing
Uphill
Did you have a
Approaching
traffic control
from the
Dark
Collision
Downhill
Unknown
signal?
opposite
Artificial
Intersection
direction
lights
Parking lot
Red
Turning
Other:
Other:
One lane
Green
Other:
Other:
Did you see other
car before collision?
2 lanes
Yellow
4 lanes
None
Yes
Weather:
Other:
No
I declare the foregoing is true and correct to the best of my knowledge.
Signature of claimant:
Date:
PLEASE SUBMIT photos and a diagram of the incident with this claim form. This documentation may also be
submitted by mail. Two estimates from shops where you would be willing to have your vehicle repaired are
required if your claim is accepted for payment. If your damage is windshield damage, one of the two estimated
must be from an auto glass shop. Per ORS 30.275, Risk Management must receive your claim within 180 days
from the date of loss.
Signature of Driver
Date
If driver is a minor, signature of driver’s guardian
Date
Page 2 of 4
Revised 3/16/2016
Form No. DAS-RM Accident Form
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