Accident Checklist  (Screen Print this)

Date of Accident__________________________________________ 

Time _________________

Accident Location:___________________________________________________

Weather conditions:___________________________________________________________

Was police called to scene:____ Yes      _____No

Which Police Dept:______________________________________

Officer name________________________ Badge #________

Report   #  ____________________________________________

Was anyone injured:__________________________________

Name other driver:____________________________________________________

Name of owner of vehicle:

_________________________________________________

Address of Owner:______________________________________________________________________

Phone: Home:_______________________________Cell____________________________

Work phone:______________________________

Year, Make & Model of car involved in accident: (other person)__________________________________________________________________________________________________

Other drivers insurance company:_____________________________

Policy Number:___________________

Other drivers License plate

______________________________________________________

What happened:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

WITNESSES:

Name and address:___________________________________________________________________________________________________________________________________________________________________________________________________________

Phone number:______________________________________________________________________________

Name and address:___________________________________________________________________________________________________________________________________________________________________________________________________________

Phone number:______________________________________________________________________________

Name and address:___________________________________________________________________________________________________________________________________________________________________________________________________________

Phone number:_________________________________________________________________________