Auto Accident Information Form

Have You Been Injured? Free First Visit

Use The Following Form To Record Accident Information

Your Name

Phone

Address

The Other Driver and His or Her Car:

Name

Street Address

City, State, Zip

Vehicle Registration/year/license number

Make/model of car and year

Does driver appear to have been drinking or using drugs

Any statements made by other driver:

Names and Addresses of Passengers in Other Car:

Name

Address

Name

Address

All Possible Witnesses:

Name

Address

Name

Address

Conditions Immediately after the Accident:

Position of your car after accident

Position of other car after accident

Location of any tire marks, auto debris, glass, dirt, etc. on road or side of road

Place of impact on other car

Name/address of wrecker that towed other car

Other conditions that affected accident

Location of point of impact in relation to center of road or some physical object

Did your car skid? If so, how many feet?

Did other car skid? If so, how many feet?

Road conditions

Traffic Conditions

Weather Conditions

Traffic Controls (traffic lights, stop signs, etc.)

The following should be filled out at scene or shortly after leaving the scene.

Date of accident

Time of accident

Location of accident

Type of road (grade, curve, etc.)

Speed of your car before accident

Speed of other car before accident

Direction of your car

Direction of other car

Were your turning?

Was other driver turning?

Did the other driver signal properly (with arm, horn, lights, etc.)?

If at night, were other vehicle's lights on?

How far away from you was the other car when you first saw it?

Other relevant facts