Accident Details
Draw a Diagram
Other Vehicle
Driver’s Name _______________________________
Date of Accident _________ Time ________ AM/PM
Location of the Accident
Show names of highways, direction (N.E.S.W.) and
direction of vehicles involved.
Address ______________________________________________
____________________________
_______________________________________________________
Company Name _____________________________________
Your speed in mph ___at the time of accident
What warning if any was given?_________
Condition of Road? ___________________
Phone # (
) ________________________________________
Vehicle Owner
______________________________________
Address ______________________________________________
(Street)
Driver’s Name________________________________________
_______________________________________________________
(City)
(State)
(Zip)
Address
_____________________________________________
(Street)
_______________________________________________________
(City)
(State)
(Zip)
Phone #
(
License Plate # _______________________________
Make/Model/Year of Vehicle _________________________
)________________________________________
Extent of Damage to Vehicle ________________________
Passengers (in your vehicle)
Name(s) and Addresses _____________________________
______________________________________________________
_______________________________________________________
_______________________________________________________
Any apparent injuries? _______________________________
_______________________________________________________
Insurance Company __________________________________
Your Vehicle Make/Model/Year
______________________________________________________
Policy #
Extent of Damage to your Vehicle ____________________
Passengers Names and Phone #’s_____________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_____________________________________________
Witnesses
In your own words, describe how the accident
occurred.
Police Response
______________________________________________________
Police Report #_______________________________________
_______________________________________________________
Officer’s Name and Badge #
_______________________________________________________
_______________________________________________________
_______________________________________________________
Address of Station ____________________________________
_______________________________________________________
Was there a citations issued?
Name
______________________________________________
Phone #_____________________________________________
_________________________
 Yes
Name
______________________________________________
Phone #_______________________________
 No
Name
_______________________________________________________
______________________________________________
Received by whom?__________________________________
_______________________________________________________
_______________________________________________________
Reason _______________________________________________
_______________________________________________________
Phone #_______________________________
Please utilize this space for any additional
information you would like to have included in
this report.
Driver’s Accident
Report
________________________________________
________________________________________
Company Name/Contact Info
Here
________________________________________
Accident Procedures
1. If the accident involves injury, serious property
damage or hazardous material spill, contact emergency
personnel 911 while at the scene. Contact your
employer immediately.
________________________________________
________________________________________
2. If your car is creating a personal safety hazard or
you are in danger move to a safer place.
________________________________________
________________________________________
________________________________________
Additional Instructions (optional)
3. Obtain information about the other people involved
in the accident or anyone who may have witnessed the
accident.
4. DO NOT talk to anyone about the accident at the
scene of the accident except your employer and/or
police.
________________________________________
________________________________________
5. DO NOT admit fault. Do NOT sign any statements
except the police report if required.
________________________________________
6. DO NOT argue at the scene of the accident. Be
courteous to everyone present.
________________________________________
________________________________________
7. Take multiple photos of scene & vehicle damage.
More pictures are better. Take pictures from every
angle and distance. Include skid marks, weather
conditions, and whole accident situation if possible
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
The Harry A. Koch Co.
402-861-7000
8. Complete this entire form, providing as much detail
as possible.