AUTO ACCIDENT REPORT

This form is to be completed in the event of an automobile accident involving a company vehicle, or employee (if accident occurs while they are performing work related duties.) If someone is injured from the accident and needs immediate medical assistance, call 911. Remain calm and but never directly admit fault.

ACCIDENT INFORMATION

Date of Accident:	Time:	( A.M. / P.M. )	Police Report #:

Location Address:	City:	State:	Zip Code:

Weather / Road conditions:

YOUR VEHICLE (VEHICLE # 1)

Make:	Model:	License Plate #:	State:

Your Injuries:

OTHER VEHICLE (VEHICLE # 2)

Make:	Model:	License Plate #:	State:

Driver’s Name:	Driver’s License #:	State of Driver’s License:

Address:	City:	State:	Zip Code:

Phone Number:	Insurance Provider:	Policy #:

Injuries:

OTHER PERSONS (PASSENGERS & PEDESTRIANS)

# 1: Name:	Age:	Phone Number:

Address:	City:	State:	Zip Code:

# 2: Name:	Age:	Phone Number:

Address:	City:	State:	Zip Code:

WITNESSES

# 1: Name:	Phone Number:

Address:	City:	State:	Zip Code:

# 2: Name:	Phone Number:

Address:	City:	State:	Zip Code:

EMERGENCY RESPONDERS

Officer(s) Name:	( Police / Sherriff / Trooper )

Transported for medical care by Ambulance: ( YES / NO )	Hospital:

Diagram of the Accident Scene Show the position of all vehicles, pedestrians, etc., using the symbols below. YOUR Vehicle (2, 3, …) Other vehicles, numbered successively (2, 3, 4, …) Pedestrians Traffic Signals Stop Signs
File a copy for your records, and submit completed form to: