ATTENTION
If You Were Involved in an Accident and You or Someone Else is Seriously Injured, Please Call 911 for Immediate Medical Help
EMERGENCY DIAL 9-1-1 NOW
ARE YOU A DRIVER OR ARE YOU A PEDESTRIAN?
PLEASE ENTER YOUR PHONE NUMBER:
INSURANCE CARD OF OTHER PERSON INVOLVED IN ACCIDENT
DRIVER’S LICENSE OF OTHER PERSON INVOLVED IN ACCIDENT
YOUR VEHICLE REGISTRATION
VEHICLE REGISTRATION OF OTHER PERSON INVOLVED IN ACCIDENT
PHOTOS OF ACCIDENT DAMAGE
VEHICLE INVOLVEMENT — Choose one of the following that describes the accident you were involved in:
VEHICLE DAMAGE — Indicate if the accident exceeds the $1,000 threshold for property damage to any one vehicle or property caused by the accident, and describe vehicle damage.
DRIVER OF MOTOR VEHICLE 1
VEHICLE DAMAGE DIAGRAM — Enter numbers from this diagram which corresponds to damage to your vehicle from the accident
Motor Vehicle 1 Property Damage
(Place up to 5 Numbers):
1) Driver’s Side
2) Hood
3) Front Passenger’s Side
4) Second Row Left Passenger’s Side
5) Bottom of Vehicle
6) Roof of Vehicle
7) Second Row Right Passenger’s Side
8) Third Row Left Passenger’s Side
9) Vehicle Trunk / Cargo Bed
10) Third Row Right Passenger’s Side
11) Left Rear Corner
12) Left Rear Wheel
13) Left Front Wheel
14) Left Front Corner
15) Front of Vehicle
16) Right Front Corner
17) Right Front Wheel
18) Right Rear Wheel
19) Right Rear Corner
20) Rear of Vehicle
DRIVER OF MOTOR VEHICLE 2
VEHICLE DAMAGE DIAGRAM — Enter numbers from this diagram which corresponds to damage to your vehicle from the accident
Motor Vehicle 1 Property Damage
(Place up to 5 Numbers):
1) Driver’s Side
2) Hood
3) Front Passenger’s Side
4) Second Row Left Passenger’s Side
5) Bottom of Vehicle
6) Roof of Vehicle
7) Second Row Right Passenger’s Side
8) Third Row Left Passenger’s Side
9) Vehicle Trunk / Cargo Bed
10) Third Row Right Passenger’s Side
11) Left Rear Corner
12) Left Rear Wheel
13) Left Front Wheel
14) Left Front Corner
15) Front of Vehicle
16) Right Front Corner
17) Right Front Wheel
18) Right Rear Wheel
19) Right Rear Corner
20) Rear of Vehicle
ACCIDENT DIAGRAM — Select one of the 9 diagrams (numbered 0-8) below if it describes the accident, or draw your own diagram, take a photo of it and drag and drop the photo into the box indicated below.
ACCIDENT LOCATION — Enter the county, locality and street(s) where the accident occurred.
Check the box if there is an interesting street. If available, identify a permanent landmark nearby,
such as a business, school, shopping mall, parking lot, water tower, railroad, mountain or cell tower.
ALL INVOLVED — list the names of all persons involved in the accident, and provide the date of death if anyone was killed in, or as a result of, the accident.
If more than four people were involved, complete another report. In the ALL INVOLVED section
of that report, provide the required information for everyone else involved in the accident.
ALL INVOLVED IN THE ACCIDENT
INJURY (Columns 16A - C) — Check all columns(s) that apply and DESCRIBE INJURIES:
A — Severe lacerations, broken or distorted limbs, skull fracture, crushed chest, internal injuries, unconscious when taken from the accident scene, unable to leave accident scene without assistance.
B — Lump on head, abrasions, minor lacerations.
C — momentary unconsciousness, limping, nausea, hysteria, complaint of pain (no visible injury), whiplash (complaint
of neck and head pain)
Enter the following codes in the appropriate columns in the section above for each person involved in the accident:
WHICH VEHICLE OCCUPIED (Column 8) — Enter the appropriate number or letter
POSITION IN/ON VEHICLE (Column 9) — Enter the number from this diagram which corresponds to each person’s position:
SAFETY EQUIPMENT USED (Column 10)
1) None
2) Lap Belt
3) Shoulder Restraint
4) Lap Belt Restraint
5) Child Restraint Only
6) Helmet (Motorcycle Only)
7) Air Bag Deployed
8) Air Bag Deployed / Lap Belt
9) Air Bag Deployed / Shoulder Restraint
A) Air Bag Deployed / Lap Belt Restraint
B) Air Bag Deployed / Child Restraint
O) Other
In-Line Skater / Bicyclist
C) Helmet Only
D) Helmet / Other
E) Pads Only
F) Stoppers Only
Be sure your answers are marked INSIDE THE BOXES BELOW WHERE APPLICABLE.
PEDESTRIAN / BICYCLIST / OTHER PEDESTRIAN LOCATION
PEDESTRIAN / BICYCLIST / OTHER PEDESTRIAN ACTION
ROADWAY SURFACE CONDITION
PRE-ACCIDENT VEHICLE ACTION
