Automobile Accident Report
Date of Accident: ______________________ Time: ________________
Location of Accident: _____________________________________________________
State: _____________________________ City and/or County: ____________________
Address or Cross Roads of Closest Intersection: ________________________________
_______________________________________________________________________
Driver and vehicle Information:
Name: _____________________________________
Campus Phone Number: _____________________________________
Vehicle year/make/model: _____________________________________
License Plate Number: _____________________________________
Information about the other driver and vehicle:
Name: ______________________________________
Address: ______________________________________
Phone Number: ______________________________________
Insurance Company: ______________________________________
Policy Number: ______________________________________
Vehicle year/make/model: ______________________________________
License Plate No: ______________________________________
Witnesses to the Accident:
Name: ___________________________ Name: ____________________________
Address: ___________________________ Address: ____________________________
__________________________________ _________________________________
Phone Number: ______________________ Phone Number: ______________________
Passenger Witness Passenger Witness
Details of Accident:
Indicate on diagram position & Direction of vehicles and/or pedestrians
Accident Description: _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Use back of Sheet for additional space if required
Injured Persons/Passengers
Was anyone injured? Yes _____ No _____
If yes, complete the following:
Name: _____________________________ Name: __________________________
Address: _____________________________ Address: __________________________
Phone number: ________________________Phone number: _____________________
Driver Passenger Pedestrian Driver Passenger Pedestrian
Was an Ambulance called? Yes _____ No _____
Additional Information
:
Were Police called? Yes _____ No _____
If so, which Department: _______________________________________
Officer’s Name: _______________________________________
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