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ACCIDENT INFORMATION
FORM
Fill Out This Form at the scene of the accident
THE OTHER DRIVER AND CAR
Name of other driver _________________________________
Street address __________________________________
City __________________________________
State __________________________________
Vehicle registration (car license)number __________________________________
Make and type of car ________________ Year __________
Number of driver's license of other driver __________________________________
Has other driver apparently been drinking? __________________________________
Any verbal statement made by other driver as to cause of accident: __________________________________
NAMES AND ADDRESSES OF
PASSENGERS IN OTHER CAR
Name __________________________________
Address __________________________________
Name __________________________________
Address __________________________________
Name __________________________________
Address __________________________________
NAME AND ADDRESSES OF ALL POSSIBLE WITNESSES TO ANY FACT
Name __________________________________
Address __________________________________
Name __________________________________
Address __________________________________
Name __________________________________
Address __________________________________
SPECIAL CONDITIONS TO NOTE IMMEDIATELY FOLLOWING ACCIDENT
Position of your car after accident
__________________________________
Position of other car after accident
__________________________________
Location of any tire marks, blood, broken glass, dirt, etc., on road or side
of road
__________________________________
Location of point of impact in relation to center of road or some physical object
__________________________________
Did your car skidif so, how many feet?
__________________________________
Did other car skidif so, how many feet?
__________________________________
Road conditions
__________________________________
Traffic conditions
__________________________________
Weather conditions
__________________________________
Traffic controls (traffic lights, stop signs, etc.)
__________________________________
Place and extent of impact on other car
__________________________________
Name and address of any wrecker that removes other car
__________________________________
Other conditions that might have bearing on accident
__________________________________
THE FOLLOWING MAY BE FILLED OUT EITHER AT THE SCENE OR SHORTLY AFTER LEAVING
THE SCENE
Date of accident__________________________________
Time __________________________________
Location of accident __________________________________
Type of road (grade, curve, etc.)
__________________________________
Speed of your car just before accident
__________________________________
Speed of other car just before accident
__________________________________
Direction of your car
__________________________________
Direction of other car
__________________________________
Were you or other driver turning?
__________________________________
Did other driver signal properly (with arm, horn, lights, etc.)?
__________________________________
If at night, were his lights turned on?
__________________________________
How far were you from the other car when you first saw it?
__________________________________
Other pertinent facts? __________________________________
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