Traffic Accident Report Form
Date of Accident: Time:
Weather Conditions:
Road Conditions:
Your Car Other Car
License Plate #: License Plate #:
Year/Make/Model: Year/Make/Model:
Driver Name: Driver Name:
Passenger Name/Ph.: Passenger Name/Ph.:
Passenger Name/Ph.: Passenger Name/Ph.:
Driver's Information Driver's Information
Name: Name:
Phone Number: Phone Number:
Driver's License #: Driver's License #:
License State: License State:
Insurance Company Information Insurance Company Information
Insured Name: Insured Name:
Relationship to Driver: Relationship to Driver:
Insurance Company: Insurance Company:
Policy #: Policy #:
Agent/Agency Name: Agent/Agency Name:
Police Report Information
Responding Department:
Officer's Name:
Badge Number:
Police Report Number:
Description of Accident:






What to do if you are involved in an auto accident.

  1. Find out if anyone is injured.Call for help if people are injured and avoid moving a severely injured person.
  2. Protect the scene. Try to keep things as they are. It is very important to keep yourself, others, and your car from further damage. Set up flares, get off the road, etc.
  3. Collect information. Get pictures (if possible). Using this form, gather names, addresses, witness information, insurance information, driver license information, etc. Don't be afraid to point out anything unusual about how the accident occurred. Some accidents are caused intentionally. Tell law enforcement. Don't confront the individual. Then, go home and write down everything you can remember while it's still fresh in your mind.
  4. Finally, get in touch with your insurance company as soon as possible. Many companies have emergency response vehicles that can respond to the scene and help with your report and assessment.

Additional Comments or Accident Diagram

Courtesy of Insurance4USA