Accident Report Page 2
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1
2ACCIDENT REPORT FORM AND MAP!
The Highway Traffic Act requires the driver of a vehicle involved in an accident to give written
information to anyone who was injured or whose property was damaged.
Which Way is North?
Use box for cars and
DO YOU HAVE A CELL PHONE or CAMERA?
The weather and road conditions during the accident:
arrows for path of
If possible — post-accident photos of the vehicles;
(Circle an
______________________________________________
vehicle:
photos and diagrams of the Accident Scene.
end)
Date: D _______________ M __________ Y _________
______________________________________________
Time: ____________________________ __ AM __ PM
______________________________________________
Light: Dawn __
Dusk __
Night __
Day __
(Mark
Use this Diagram t help you make a sketch of The Accident Site:
point of
Location: ______________________________________
contact)
______________________________________________
OTHER VEHICLE:
Make: ________________________________________
Model: _______________________________________
Year: __________ Licence Plate: ________ ________
Driver’s Name: First: ____________________________
Last: _________________________________________
Address: ______________________________________
______________________________________________
Damage to
Damage to
Ph: __________________ Work: __________________
OR, Draw your own:
YOUR
Vehicle:
Other Vehicle:
Drivers Licence #:
_______________________________ Prov: _________
NOTIFIED POLICE:
Date: D _______________ M __________ Y ________
Report #:
_____________________________________
WITNESS 1: First Name: __________________________
Last: _________________________________________
Address: ______________________________________
______________________________________________
Ph: __________________ Work: __________________
TOWING SERVICES: Inside Winnipeg: 204-985-4665 Inside Brandon: 204-729-9510
WITNESS 2: First Name: __________________________
MPI Info:
Quick eGLASS Claim: 487-1860
445 King Street
Hours
Last: _________________________________________
Mon - Fri: 7am - 9pm
125 King edward Street
Reporting Damage Claims
Saturday: 8:30am - 4pm
“other” than Glass:
930 St. Mary’s Road
Address: ______________________________________
Closed Sunday
Inside Winnipeg: 204-985-7000
420 Pembina Highway
Reporting Glass Claims:
______________________________________________
We will give you the first available
1103 Pacific Avenue
Inside Winnipeg: 204-985-7000
estimate appointment at one of
Ph: __________________ Work: __________________
Outside Winnipeg: 1-800-665-2410
the following locations . . .
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