Print this accident form and keep it in your car along with a disposable camera. It is important that you fill this form out as best you can. If you are able to do so safely, you can use the camera to take pictures of the accident scene including all vehicles and individuals involved in the accident. Remember, you are not obligated to speak with the other driver's insurance company, no matter what they tell you they are not on your side.
ACCCIDENT INVESTIGATION FORMDate:_____________________________ Time:___________________
Location: _________________________ City:___________________
__________________________
What Happened:___________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
OBTAIN THE FOLLOWING INFORMATION FROM THE OTHER DRIVERName:_____________________________________
Address:__________________________________________
Phone Number:(work)________________ (home)_______________
Driver's License Number:_____________ State:________
Insurance Company:____________________________________
Insurance Policy Number:________________________________
OTHER Car's License Plate:___________________ State:________
Make and Model of OTHER Car:______________ Color of OTHER Car:_____
Owner of OTHER Car:(if different from driver)________________________
Owner of OTHER Car's Address:____________________________________
Owner of OTHER Car's Phone Number:(work)____________ (home)___________
Were there any passengers in the OTHER car? YES NO
If yes, names and phone numbers for each passenger:_______________________
_____________________________________________________________________
Was there a police report taken? YES NO
Which police department arrived at the accident?________________
What is the police report number?__________________
Did anyone witness the accident? YES NO
Name of witness:________________________________________
Witness Address:________________________________________
Witness Phone Number:(work)______________ (home)____________
Name of witness:________________________________________
Witness Address:________________________________________
Witness Phone Number:(work)______________ (home)____________
Name of witness:__________________________________________
Witness Address:__________________________________________
Witness Phone Number:(work)______________ (home)_____________
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© 2001 Wolfberg Law Offices All Rights Reserved. See Copyright
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