PERSONAL REPORT OF ACCIDENT

This form should be completed when a traffic accident occurs and a law enforcement officer is not called to make a report. This
report is for your personal use and should not be mailed to the Department of Driver Services, as it will be destroyed upon
receipt.
INSTRUCTIONS:
1. Answer all questions to the best of your knowledge. If unable to answer any questions, mark “not known”.
2. Give exact time of accident (date, day and hour).
3. Under “Location of Accident” show sufficient information to locate exact scene of the accident.
4. Print or type all names and addresses.
5. Sign the report in the space provided on the reverse side.
6. Report must be complete as to exact names, birth dates, and drivers license numbers.
7. Use a second report form or a sheet of plain paper of the same size to report additional vehicles, injured persons, or witnesses, or
any other information for which there is insufficient space.
Time Date of Day of DO NOT WRITE IN
Accident________ Week________ Hour______A.M.______P.M. Weather________________________________ THIS SPACE
(Clear, Raining, Fog, Etc.)
Place Where
L Accident Occurred:
City, Town
County________________________ Or Township __________________________
O If accident was outside city _______ miles _______

C nearest town. Use two dis-

tances and two directions
{
limits indicate distance from
_______ miles _______}{
south-north

east-west
of
} ___________
" limits of

" center of City or Town

A if necessary.
ROAD ACCIDENT
OCURRED ON:______________________________________________________________________________________
T Give name of street or highway number, (U.S. or State). If no highway number, identify by name.

I Check and
" At its intersection with: _______________________________________________________
Name of intersecting street or highway number
_______ feet _______
O complete one OR _______________________________

N
" Not at intersection: { south-north
_______ feet _______
east-west
} of
show nearest intersecting street or high-
way, house number, bridge, driveway or
other identifying landmark.

V YOUR VEHICLE NUMBER 1

Vehicle Approximate cost
E _________________________________________________ License Plate _________________________________ to repair vehicle _______________
Year Make Type (sedan, truck, taxi, bus, etc.) Year State Number

H Driver________________________________________ ________________________________________________________________________
Full Name Street City and State
I Driver’s
Occupation____________________________________
Driver’s Driver’s
License________________________ Birth Date__________________Age_____Sex______
C Carpenter, Sales Clerk, Etc. State Number Mo. Da Yr
Owner_____________________________________________________________________________________Owner’s Birth Date_________________
L Parts of
Full Name Street City and State
Owner’s
Mo Da Yr

Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________

E Is this vehicle covered by " Yes IF YES TO EITHER SHOW State Number
Name ________________________________________________________
automobile liability insurance? " No INSURANCE COMPANY
S If vehicle not covered, did driver " Yes _______________________
have liability policy applicable? " No Show Policy Number Here
Show name of insurance company not name of insurance agency.

Address_______________________________________________________
OTHER VEHICLE NUMBER 2 Vehicle Approximate cost
Space _________________________________________________ License Plate _________________________________ to repair vehicle _______________
for Year Make Type (sedan, truck, taxi, bus, etc.) Year State Number
any
third Driver________________________________________ _________________________________________________________________________
vehicle Full Name Street City and State
on Driver’s Driver’s Driver’s
reverse Occupation____________________________________ License________________________ Birth Date__________________Age_____Sex______
side. Carpenter, Sales Clerk, Etc. State Number Mo. Da Yr
Total Owner_____________________________________________________________________________________Owner’s Birth Date_________________
vehicles Full Name Street City and State Mo Da Yr
involved Parts of Owner’s
Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________
State Number
Is this vehicle or driver covered by automobile liability insurance? " Yes " No If Yes show name of Insurance Company_________________________
DAMAGE TO PROPERTY Approximate
OTHER THAN VEHICLE___________________________________________________________________________ cost to repair $____________________
NAME OBJECT AND STATE NATURE OF DAMAGE
NAME AND ADDRESS OF OWNER OF DAMAGED PROPERTY________________________________________________________________________________
 3rd Vehicle No. 3 (If third vehicle Involved) Vehicle Approximate cost
_________________________________________________ License Plate _________________________________ to repair vehicle _______________
V Year Make Type (sedan, truck, taxi, bus, etc.) Year State Number

E Driver________________________________________ _________________________________________________________________________
Full Name Street City and State
H Driver’s Driver’s Driver’s
Occupation____________________________________ License________________________ Birth Date__________________Age_____Sex______
I Carpenter, Sales Clerk, Etc. State Number Mo. Da Yr
Owner_____________________________________________________________________________________Owner’s Birth Date_________________
C Full Name Street City and State Mo Da Yr
Parts of Owner’s
L Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________
State Number
E Is this vehicle or driver covered by automobile liability insurance? " Yes " No If Yes show name of Insurance Company_________________________
" Driver In Vehicle
I Name__________________________________________________Address_______________________________ " Passenger No.____________
Injured " Pedestrian
N Age________ Sex________ Race________ taken to__________________________________________________ " Specify other_______________
Nature and Attending
J Did injured die?_______________ extent of injuries__________________________________________ Doctor_________________________________
U
R " Driver In Vehicle
Name__________________________________________________Address_______________________________ " Passenger No.____________
E Injured " Pedestrian
Age________ Sex________ Race________ taken to_______________________________________________ " Specify other_______________
D
Total Nature and Attending
Injured Did injured die?_______________ extent of injuires__________________________________________ Doctor_________________________________

Light Conditions What Pedestrian Was Doing

Pedestrian was going " " " " " Across or into_________________________From___________________To____________________
" Daylight N S E W Street name, highway no.
" Crossing or entering at intersection " Walking in roadway-with traffic " Pushing or working on vehicle " Other in roadway
" Dawn or Dusk
" Crossing or entering not at intersection " Walking in roadway-against traffic " Other working in roadway " Not in roadway
" Darkness
" Getting on or off vehicle " Standing in roadway " Playing in roadway

What Drivers Intended To Do: (Check one for each driver)

Driver Driver Driver Driver

1 2 3 1 2 3 1 2 3 1 2 3
" " " Go straight ahead " " " Make Left Turn " " " Start in Traffic " " " Remain stopped in traffic lane
" " " Overtake and pass " " " Make U Turn " " " Start from parked position " " " Remain Parked
" " " Make right turn " " " Make right turn " " " Back " " " Get out of parked or stopped vehicle

Witnesses:

Name_________________________________________________________ Address__________________________________________ Age________________

approximate
Name__________________________________________________________ Address___________________________________________ Age________________
approximate

DESCRIBE WHAT HAPPENED:

Refer to vehicles by number. If more space is needed, use another report form or a sheet of plain paper of the same size.

Signature________________________________________________ Address___________________________________________________ Date_______________

Signature of person submitting report is required. Complete both sides of this form.