Accident Report Form
(Print this form and keep in your glove box)


            

 

Call 724-282-4293 for all your auto body needs
Accident Details
Date: Time Street/Intersection
Police Dept./Sheriff Report #
Other Vehicle Information
Year Make Model
License Plate # Color # Passengers
Other Driver Information
Last Name First Name
Street City State Zip
Home Phone Business Phone Cell Phone
Driver License # Insurance Company Policy #
Registered Owner of Other Vehicle (if different)
Last Name First Name
Street City State Zip
Home Phone Business Phone Cell Phone
Driver License # Insurance Company Policy #
Other Vehicle passenger Information
1. Last Name First Name
Street City State Zip
Home Phone Business Phone Cell Phone
Driver License # Insurance Company Policy #
2. Last Name First Name
Street City State Zip
Home Phone Business Phone Cell Phone
Driver License # Insurance Company Policy #
Witness Information
1. Last Name First Name
Street City State Zip
Home Phone Business Phone Cell Phone
2. Last Name First Name
Street City State Zip
Home Phone Business Phone Cell Phone

It may be useful to make a diagram on the back of this form showing the position of all vehicles involved in the accident. Include: direction vehicle(s) were traveling in, point of impact, location of traffic lights/signs and intersections with street names