1. Agency Name 2. Person to Contact 3. Phone 4. Loc. Code
5. State Vehicle Driver’s Name 6. Personnel Number 7. Date of Accident
9. Exact Location of Accident (Use street markers, mileage markers, etc., to pinpoint location)
12. State Vehicle Driver’s Address (Street No) City State Zip Code 13. Home Phone 14. Work Phone
15. Driver’s License No. 16. Age 18. Vehicle’s Owner’s Name and Address
19. Year Vehicle 20. Make Vehicle 21. Model Vehicle 22. Body Type 23. Vehicle Lic. No. / Equip No. / VIN
24A. Where can the Vehicle be Seen ? 24B. Describe Damage
25. Other Vehicle Driver’s Name 27. Driver’s License No. 28. Age
-- --
30. Other Vehicle Driver’s Address (Street No.) City State Zip Code 31. Home Phone 32. Work Phone
33. Vehicle Owner’s Name and Address (Street No.) City State Zip Code
34. Year Vehicle 35. Make Vehicle 36. Model Vehicle 37. Body Type 38. Vehicle I.D. No. or Lic. No. 39. Where can the vehicle be seen ?
40. Other Vehicle Insurance Co. 41. Policy No.
42. Describe Damage 43.Estimated Amount
$
44. Name and Address 45. Phone
44. Name and Address 45. Phone 49. Report No. (Item No.)
53. (Specify)
50. Name and Address 51. 52. Phone 53. (Specify)
54. State Driver’s Signature 55. Name of Driver’s immediate Supervisor and Phone No.
Print Form
10.
DESCRIBE
HOW ACC.
HAPPENED
44. Name and Address 45. Phone
50. Name and Address 51. 52. Phone
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
DA 2041
Rev. 12/98
ACCIDENT REPORT
LOUISIANA STATE DRIVER SAFETY PROGRAM
Submit report to ORM
within 48 hours of accident
SUPERVISOR
TO COMPLETE
FIRST 4 ITEMS
8. Time of Accident
AM
PM
11.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.
17. Sex
M F
OTHER VEHICLE INFORMATION
If more than one vehicle is involved, submit additional sheet with information on other vehicle(s).
26. Driver’s Social Security No.
no longer required
29. Sex
M F
INJURED
46.
PED
47.
Ins. Veh.
48.
Other Veh.
49. Police Investigated ?
Yes No
49. Type Report
State Sheriff City
46.
PED
47.
Ins. V
eh.
48.
Other Veh.
46.
PED
47.
Ins. Veh.
48.
Other Veh.
WITNESSES OR PASSENGERS
Witness
Passenger
53.
PED
53.
Ins. Veh.
53.
Other Veh.
Witness
Passenger
53.
PED
53.
Ins. Veh.
53.
Other Veh.
Submit by Email
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