Fillable DA 2041 9/14 ACCIDENT REPORT LOUISIANA STATE DRIVER SAFETY PROGRAM

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DA 2041 9/14 ACCIDENT REPORT LOUISIANA STATE DRIVER SAFETY PROGRAM

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DA 2041
Rev. 9/14
ACCIDENT REPORT
LOUISIANA STATE DRIVER SAFETY PROGRAM
(If you do not know your location code, please refer to http://www.laorm.com/documents/loccodes.pdf)
Submit report to ORM
within 48 hours of accident
SUPERVISOR
TO COMPLETE
FIRST 4 ITEMS
Agency Name (Owner)
Person to Contact
Phone
Vehicle Owner's Loc. Code
State Vehicle Driver’s Name
Driver's Agency Name and Location Code
Date of Accident
Time of Accident
AM
PM
Exact Location of Accident (Use street markers, mileage markers, etc., to pinpoint location)
1
DESCRIBE
HOW ACC.
HAPPENED
Seat Belt in Use
Yes No
STATE VEHICLE INFORMATION
If other then vehicle damage, fill in as much as possible under “Other Vehicle” section substituting property owner information for vehicle driver.
State Vehicle Driver’s Address (Street No)
City
State
Zip Code
Home Phone
Work Phone
Driver’s License No.
Age
Sex
M F
Vehicle’s Owner’s Name and Address
Year Vehicle
Make Vehicle
Model Vehicle
Body Type
Vehicle Lic. No. / Equip No. / VIN LPAA Fleet ID No.
Where can the Vehicle be Seen ?
Describe Damage
OTHER VEHICLE INFORMATION
If more than one vehicle is involved, submit additional sheet with information on other vehicle(s).
Other Vehicle Driver’s Name
Driver’s Social Security No.
--no longer required--
Driver’s License No.
Age
Sex
M F
Other Vehicle Driver’s Address (Street No.)
City
State
Zip Code
Home Phone
Work Phone
Vehicle Owner’s Name and Address (Street No.)
City
State
Zip Code
Year Vehicle
Make Vehicle
Model Vehicle
Body Type
Vehicle I.D. No. or Lic. No.
Where can the vehicle be seen ?
Other Vehicle Insurance Co.
Policy No.
Describe Damage
Estimated Amount
$
INJURED
Name and Address
Phone
4
PED
4
Ins. Veh.
4
Other Veh.
Police Investigated ?
Yes No
Name and Address
Phone
PED
4
Ins. Veh.
Other Veh.
Type Report
State Sheriff City
Name and Address
Phone
PED
4
Ins. Veh.
4
Other Veh.
Report No. (Item No.)
WITNESSES OR PASSENGERS
. Name and Address
Witness
Passenger
Phone
PED
Ins. Veh.
Other Veh.
(Specify)
Name and Address
Witness
Passenger
Phone
PED
Ins. Veh.
Other Veh.
(Specify)
State Driver’s Signature
Name of Driver’s immediate Supervisor and Phone No.
Submit by Email
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DA 2041 914 ACCIDENT REPORT LOUISIANA STATE DRIVER SAFETY PROGRAM

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Completed 21 January 2020

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