Accident Report
Other Driver Information
Name ______________________________________________________ Vehicle year _____________________________________________________
Address ____________________________________________________ Make & Model ____________________________________________________
Telephone (day) ______________________________________________ Insurance Company ________________________________________________
Telephone (night) _____________________________________________ Policy# __________________________________________________________
Vehicle Owners name if not driver _________________________________ Expiration ________________________________________________________
Address (if not driver) __________________________________________
Drivers Licence# ______________________________________________
Expiration ____________________________________________________
The Accident Complete the diagram using arrows to indicate direction of vehicles and point of
contact
What happened? Describe damage to vehicles and
property. _____________________________________________________
____________________________________________________________
____________________________________________________________
What injuries did people have?____________________________________
____________________________________________________________
____________________________________________________________ D- Driver 1 – Other party 2- Other party
Witness
Name _______________________________________________________ Name _______________________________________________
Address ______________________________________________________ Address _____________________________________________
Phone ________________________________________________________ Phone ______________________________________________
Police
Report incident to police within 7 days if:
- Fatality
- Serious Injury (someone hospitalized)
- Unlicensed driver or unregistered vehicle
-Failure to obtain particulars from other party- Suspected drug or alcohol use by other driver