ACCIDENT INFORMATION FORM
Print and Keep This In Your Glove Box
This document contains important information and should be completed in case of an accident
Remain at the scene of the accident and stay calm.
Notify the police.
Exchange information with other driver.
Other Driver:
Name: ___________________________________________
Address: _________________________________________
Telephone Number: _________________________________
Driver's License Number: _____________________________
Insurance Company: _________________________________
Policy Number: ______________________________________
Year, Make, Model, Color of Vehicle: _____________________
License Tag Number: __________________________________
Owner (If not the driver):
Name: ___________________________________________
Address: _________________________________________
Telephone Number: _________________________________
Driver's License Number: _________________________________
Insurance Company: _________________________________
Policy Number: _________________________________
Witness 1:
Name: ___________________________________________
Address: _________________________________________
Telephone Number: _________________________________
Witness 2:
Name: ___________________________________________
Address: _________________________________________
Telephone Number: _________________________________
Passenger:
Name: ___________________________________________
Address: _________________________________________
Telephone Number: _________________________________
Statement by Other Driver:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Police:
Police Department: __________________________________
Investigating Officer: _________________________________
Badge Number: _____________________________________
Report Number: _____________________________________
Accident Information:
Date of Accident: ____________________________________
Time of Accident: ____________________________________
Weather Condition: ___________________________________
Accident Diagram:
Show the following:
Street you were on: ___________________________________
Your direction of travel: _________________________________
Street other driver was on: _______________________________
Other driver's direction of travel: ___________________________
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