Field | Driver 1 (Insured) | Driver 2 (Other Party) | |
|---|---|---|---|
Name | |||
Phone Number | |||
Email Address | |||
Policy/Certificate Number | |||
Insurance Provider Name | |||
Contact Person/Agent Name | |||
Relationship to Insured (if not the policyholder) |
Field | Details | |
|---|---|---|
Date of Accident | ||
Time of Accident | ||
Street Address or Intersection | ||
City/Town | ||
Region/State/Province | ||
Weather Conditions (e.g., Clear, Rain, Snow, Fog) | ||
Road Conditions (e.g., Dry, Wet, Icy, Gravel) | ||
Lighting Conditions (e.g., Daylight, Dusk, Dark - Street Lights on/off) |
What was the primary cause of the accident, in your opinion?
Speed of your vehicle at impact:
Speed of the other vehicle at impact (estimate):
Were traffic control devices present? (e.g., Stop Sign, Traffic Light, Yield Sign)
Briefly describe the direction of travel for both vehicles and the sequence of events leading up to the impact:
Field | Your Vehicle (Driver 1) | Other Vehicle (Driver 2) | |
|---|---|---|---|
Year, Make, Model | |||
Vehicle Identification Number (VIN) | |||
License Plate Number | |||
Jurisdiction of Plate (Country/Region) | |||
Where is the vehicle currently located? | |||
Primary Area of Damage (e.g., Front Bumper, Driver-Side Door, Rear Quarter Panel) |
Field | Driver 1 (Insured) | Driver 2 (Other Party) | |
|---|---|---|---|
Driver's License Number | |||
Issuing Authority (Country/Region) | |||
Was the driver wearing a seatbelt? | |||
Was the driver injured? | |||
Hospital/Clinic (if treated) |
List all passengers in your vehicle (include name, relationship, and if injured):
Passenger Name | Relationship | Injured? | ||
|---|---|---|---|---|
1 | ||||
2 | ||||
3 | ||||
4 | ||||
5 |
Were there passengers in the other vehicle?
Were police/law enforcement called to the scene?
Were there any independent witnesses to the accident?
Witness 1 Name:
Witness 1 Phone:
Witness 1 Email:
Witness 2 Name:
Witness 2 Phone:
Witness 2 Email:
Was any property other than the vehicles damaged? (e.g., fence, pole, building)
Owner's Name and Contact Information (if known):
Were there any fatalities as a result of the accident?
Briefly describe the extent of any personal injuries to any party (e.g., minor cuts, broken limb, hospitalization):
Completed Accident Report Form
Photos of vehicle damage (both vehicles)
Photos of the accident scene (showing road conditions, traffic controls)
Copy of Police Report (if available)
Contact information collected from all parties and witnesses
I certify that the information provided above is accurate to the best of my knowledge and belief.
Driver 1 (Insured) Signature: