Vehicle Accident Incident Report Form - Blue Horizon

ADVERTISEMENT
VEHICLE ACCIDENT / INCIDENT REPORT FORM
 Remain calm
 Call your supervisor or the office IMMEDIATELY from the site of the accident.
 Complete this form as soon as possible, at the scene if possible, and turn in to your supervisor.
 Your supervisor will take care of reporting to their insurance center.
 If safe to leave vehicles in traffic, do not move vehicles until told to do so by Police.
 Call police to investigate accident.
______________________
____________________________________________
Date
Time of Accident
__________________________________________________________________________________
Location of Accident
__________________________________________________________________________________
(Street address, City)
INSURED’S VEHICLE
OTHER VEHICLE INFORMATION
_____________________________________
_________________________________________
Driver’s name
Driver’s Name
_____________________________________
_________________________________________
Driver’s Address
Driver’s Address
_____________________________________
_________________________________________
Driver’s License Number
Driver’s License Number
_____________________________________
_________________________________________
Vehicle Make and Model
Driver’s Date of Birth
_____________________________________
_________________________________________
Vehicle License Number
Number of People in the Vehicle
_________________________________________
WITNESSES (Over for additional space)
Owner of Vehicle
_____________________________________
_________________________________________
Name
Owner’s Address
_____________________________________
_________________________________________
Address
Vehicle Make
_____________________________________
_________________________________________
Phone Number
Model
Year
Color
_____________________________________
_________________________________________
Name
Vehicle Serial Number
_____________________________________
_________________________________________
Address
State of Registration
Plate #
_____________________________________
_________________________________________
Phone Number
Insurance Company
_________________________________________
Policy Number
_________________________________________
Name & Phone Number of Agent
VEHICLE ACCIDENT / INCIDENT REPORT FORM
 Remain calm
 Call your supervisor or the office IMMEDIATELY from the site of the accident.
 Complete this form as soon as possible, at the scene if possible, and turn in to your supervisor.
 Your supervisor will take care of reporting to their insurance center.
 If safe to leave vehicles in traffic, do not move vehicles until told to do so by Police.
 Call police to investigate accident.
______________________
____________________________________________
Date
Time of Accident
__________________________________________________________________________________
Location of Accident
__________________________________________________________________________________
(Street address, City)
INSURED’S VEHICLE
OTHER VEHICLE INFORMATION
_____________________________________
_________________________________________
Driver’s name
Driver’s Name
_____________________________________
_________________________________________
Driver’s Address
Driver’s Address
_____________________________________
_________________________________________
Driver’s License Number
Driver’s License Number
_____________________________________
_________________________________________
Vehicle Make and Model
Driver’s Date of Birth
_____________________________________
_________________________________________
Vehicle License Number
Number of People in the Vehicle
_________________________________________
WITNESSES (Over for additional space)
Owner of Vehicle
_____________________________________
_________________________________________
Name
Owner’s Address
_____________________________________
_________________________________________
Address
Vehicle Make
_____________________________________
_________________________________________
Phone Number
Model
Year
Color
_____________________________________
_________________________________________
Name
Vehicle Serial Number
_____________________________________
_________________________________________
Address
State of Registration
Plate #
_____________________________________
_________________________________________
Phone Number
Insurance Company
_________________________________________
Policy Number
_________________________________________
Name & Phone Number of Agent
VEHICLE ACCIDENT / INCIDENT REPORT FORM
ACCIDENT
__________________________________________________________________________________
Direction your car was traveling
__________________________________________________________________________________
Speed of insured’s vehicle
__________________________________________________________________________________
Were your lights on?
__________________________________________________________________________________
Did the other driver signal?
__________________________________________________________________________________
What kind of signal?
__________________________________________________________________________________
Were his/her lights on?
__________________________________________________________________________________
Weather at the time of accident
__________________________________________________________________________________
Condition of the road at time of accident
__________________________________________________________________________________
Was the speed limit posted? What was it?
__________________________________________________________________________________
Were all persons in insured’s vehicle wearing seat belts?
__________________________________________________________________________________
Were all persons in other vehicle wearing seat belts?
__________________________________________________________________________________
Did Police make report of accident?
City, State, or County Police
Insured’s description of accident:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
____________________
__________________________________________
Date of Report
Signature of Insured’s Driver

Download Vehicle Accident Incident Report Form - Blue Horizon

227 times
Rate
4.4(4.4 / 5) 11 votes
ADVERTISEMENT
Page of 2