Please print this page and keep in your automobile in case of an accident.

IN CASE OF ACCIDENT 

NEVER "Make a Deal" for damages. 

NEVER leave the scene of even a MINOR accident. 

NEVER accept an offer of cash, check or "private" settlement. 

NEVER disavow injury to you or your passengers. 

NEVER offer to pay ANYTHING even if you think you are at fault. 

NEVER administer first aid unless you are LICENSED to do so. 

ALWAYS (when conditions permit) move to shoulder or other "SAFE AREA" to prevent further damage. 

ALWAYS ask someone to summon police and seek medical assistance. Repeat at 5-minute intervals. 

ALWAYS remember the 3 C's: Remain CALM, COURTEOUS, CONSISTENT in your version of the accident. 

ALWAYS obtain complete information from those involved. See below. 

ALWAYS complete this report on the scene - not later on. 

ALWAYS obtain the names of witnesses including addresses and phone numbers. 

ALWAYS notify the owner of the car you are driving as soon as possible. 

YOUR VEHICLE- Complete beforehand if possible 

License Plate # ____________________________________ 

Make_______________ Model____________ Year_______ 

Registration / VIN # ________________________________ 

Owner's Name_____________________________________ 

Driven By_________________________________________ 

Driver License # ___________________________________ 

Address__________________________________________ 

City_________________State___________Zip___________ 

Telephone # (      )__________________________________ 

Damage___________________________________________ 

OTHER VEHICLE 

License Plate# / State _______________________________ 

Owner's Name ____________________________________ 

Driver's Name ____________________ Age______________ 

Registration / VIN # _________________________________ 

Address ________________________________________ 

City __________________State __________Zip_________ 

Home Telephone # (       )____________________________ 

Work Telephone # (       )____________________________ 

Insurance Company ________________________________ 

Policy # _________________________________________ 

Expiration Date ___________________________________ 

Damage ________________________________________ 

OTHER VEHICLE (if applicable) 

License Plate # / State _____________________________ 

Owner's Name ___________________________________ 

Driver's Name ________________________Age_________ 

Registration / VIN # _______________________________ 

Address ________________________________________ 

City___________________State _________Zip _________ 

Home Telephone # (      ) ___________________________ 

Work Telephone # (      ) ___________________________ 

Insurance Company _______________________________ 

Policy # _______________________________________ 

Expiration Date __________________________________ 

Damage _______________________________________ 

WITNESSES 

Name _________________________________________ 

Address _______________________________________ 

City ___________________State _______Zip ________ 

Telephone # (      )_______________________________ 

Name ________________________________________ 

Address _______________________________________ 

City __________________State ________Zip ________ 

Telephone # (      ) ______________________________ 

Name ________________________________________ 

Address _______________________________________ 

City __________________State ________Zip _________ 

Telephone # (      ) _______________________________ 

DESCRIPTION OF ACCIDENT your account 

Date _______________Hour _________(AM/PM)_____ 

Location ______________________________________ 

Road Condition __________________________________ 

Police Officer Name ______________________________ 

Badge #________________________________________ 

Accident Report # _______________________________ 

Circumstances __________________________________ 

_____________________________________________ 

_____________________________________________ 

_____________________________________________ 

Damage to Property of Others _____________________ 

____________________________________________ 

____________________________________________ 

PERSONS INJURED 

Name _______________________________________ 

Address _____________________________________ 

City __________________State ________Zip _______ 

Name _______________________________________ 

Address _____________________________________ 

City __________________State ________Zip_______ 

Name ______________________________________ 

Address ____________________________________ 

City _________________State ________Zip _______ 

IMPORTANT Use the diagram below to illustrate the accident.  Your car is "Vehicle A" the other car is "Vehicle B".  Others are "Vehicle C,D,E". 

1) Note the direction of each car and the direction they were traveling with arrows and compass points (N.S,E,W). 

2) Get all information on the other driver(s) requested above. 

3) Complete information on your car - see above.