"Personal Report of Accident Form - Kennesaw State University"

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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
DO NOT WRITE IN
Date of
Day of
THIS SPACE
Accident________
Week________ Hour______A.M.______P.M. Weather________________________________
(Clear, Raining, Fog, Etc.)
Place Where
L
City, Town
Accident Occurred:
County________________________ Or Township __________________________
O
If accident was outside city
_______ miles _______
{
}
limits indicate distance from
{
___________
" " " " " limits of
}
south-north
C
nearest town. Use two dis-
of
_______ miles _______
tances and two directions
" " " " " center of
City or Town
east-west
A
ry.
if necessa
ROAD ACCIDENT
OCURRED ON:______________________________________________________________________________________
T
Give name of street or highway number, (U.S. or State). If no highway number, identify by name.
I
" At its intersection with:
_______________________________________________________
Name of intersecting street or highway number
Check and
O
OR
_______ feet _______
_______________________________
complete one
{
}
south-north
show nearest intersecting street or high-
of
" Not at intersection:
way, house number, bridge, driveway or
_______ feet _______
N
other identifying landmark.
east-west
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
Driver’s
Driver’s
Occupation____________________________________
License________________________
Birth Date__________________Age_____Sex_______
C
Carpenter, Sales Clerk, Etc.
State
Number
Mo.
Da
Yr
Owner_____________________________________________________________________________________Owner’s Birth Date_________________
L
Full Name
Street
City and State
Mo
Da
Yr
Parts of
Owner’s
Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________
E
" " " " " Yes
Is this vehicle covered by
State Number
IF YES TO EITHER SHOW
Name ________________________________________________________
" " " " " No
automobile liability insurance?
INSURANCE COMPANY
S
Show name of insurance company not name of insurance agency.
" " " " " Yes
If vehicle not covered, did driver
_______________________
" " " " " No
have liability policy applicable?
Show Policy Number Here
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________________________________________________________________________________
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
DO NOT WRITE IN
Date of
Day of
THIS SPACE
Accident________
Week________ Hour______A.M.______P.M. Weather________________________________
(Clear, Raining, Fog, Etc.)
Place Where
L
City, Town
Accident Occurred:
County________________________ Or Township __________________________
O
If accident was outside city
_______ miles _______
{
}
limits indicate distance from
{
___________
" " " " " limits of
}
south-north
C
nearest town. Use two dis-
of
_______ miles _______
tances and two directions
" " " " " center of
City or Town
east-west
A
ry.
if necessa
ROAD ACCIDENT
OCURRED ON:______________________________________________________________________________________
T
Give name of street or highway number, (U.S. or State). If no highway number, identify by name.
I
" At its intersection with:
_______________________________________________________
Name of intersecting street or highway number
Check and
O
OR
_______ feet _______
_______________________________
complete one
{
}
south-north
show nearest intersecting street or high-
of
" Not at intersection:
way, house number, bridge, driveway or
_______ feet _______
N
other identifying landmark.
east-west
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
Driver’s
Driver’s
Occupation____________________________________
License________________________
Birth Date__________________Age_____Sex_______
C
Carpenter, Sales Clerk, Etc.
State
Number
Mo.
Da
Yr
Owner_____________________________________________________________________________________Owner’s Birth Date_________________
L
Full Name
Street
City and State
Mo
Da
Yr
Parts of
Owner’s
Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________
E
" " " " " Yes
Is this vehicle covered by
State Number
IF YES TO EITHER SHOW
Name ________________________________________________________
" " " " " No
automobile liability insurance?
INSURANCE COMPANY
S
Show name of insurance company not name of insurance agency.
" " " " " Yes
If vehicle not covered, did driver
_______________________
" " " " " No
have liability policy applicable?
Show Policy Number Here
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_____________________________________________________________________________________Own er’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
" Passenger
No.____________
Name__________________________________________________Address_______________________________
"
Pedestrian
Injured
N
"
Specify other_______________
Age________ Sex________ Race________
taken to__________________________________________________
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_________________________________
What Pedestrian Was Doing
Light Conditions
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
" " "
" " "
" " "
Start in Traffic
Remain stopped in traffic lane
Go straight ahead
" " " Make Left Turn
" " "
" " "
" " "
Start from parked position
Remain Parked
Overtake and pass
" " " Make U Turn
" " "
" " "
" " "
Back
Get out of parked or stopped vehicle
Make right turn
" " "
Make right turn
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.
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