Vehicle Accident Report Form
Vehicle Accident Report Form
Please provide the required information regarding the vehicular accident.
Accident Details
Date and Time of Accident
Location of Accident
Weather Conditions
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Clear
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Rainy
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Snowy
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Foggy
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Windy
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Road Conditions
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Dry
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Wet
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Type of Accident
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Rear-End Collision
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Side Impact
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Head-On Collision
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Hit and Run
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No. of Vehicles
No. of Persons Involved
Description of Accident
Was law enforcement notified?
Vehicle and Owner Information
Vehicle 1
Owner
Gender
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Male
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Female
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Address
Driver's License No.
Vehicle Make and Model
License Plate No.
Insurance Company
Policy No.
Vehicle Damage Description
Is the vehicle owner injured?
If yes, please provide details
Does the vehicle have passengers?
No. of Passengers
Vehicle 1 Passenger Details
List down the names and specify if the passengers were injured or not.
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No. |
Name |
Yes |
No |
Description of Injury |
|---|---|---|---|---|
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1 |
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2 |
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3 |
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4 |
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5 |
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Vehicle 2
Owner
Gender
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Male
-
Female
-
Address
Driver's License No.
Vehicle Make and Model
License Plate No.
Insurance Company
Policy No.
Vehicle Damage Description
Is the vehicle owner injured?
If yes, please provide details
Does the vehicle have passengers?
No. of Passengers
Vehicle 2 Passenger Details
List down the names and specify if the passengers were injured or not.
|
No. |
Name |
Yes |
No |
Description of Injury |
|---|---|---|---|---|
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1 |
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2 |
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3 |
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4 |
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5 |
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Witness Information
Witness 1
Name
Phone number
Alternative Phone number
Witness 2
Name
Phone number
Alternative Phone number
Reporting Party Information
Date and Time of Report
Name
Phone number
Name:
Date:
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