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Reporting Traffic Accident
# of Vehicles
Accident Location (City & County)
Date
MM slash DD slash YYYY
Reporting Party's Information
Driving for Employer?
Yes
No
On Private Property?
Yes
No
Time of Accident
Type
Moving
Stopped in Traffic
Parked
Pedestrain
Bicyclist
Other
Driver's First Name
Driver's Middle Initial
Driver's Last Name
Driver's Phone
Driver's Date of Birth
MM slash DD slash YYYY
Driver's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Vehicle (Year and Make)
Vehicle License Plate or VIM
Vehicle State
Vehicle Owner's First Name
Vehicle Owner's Last Name
Vehicle Owner's Date of Birth
MM slash DD slash YYYY
Damages Over $1,000?
Yes
No
Vehicle Owner's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Insurance Company Name
Policy Number
Company NAIC Number
Policy Holder Name
Policy Start Date
MM slash DD slash YYYY
Policy Termination Date
MM slash DD slash YYYY
Other Party's Information
Type
Moving
Stopped in Traffic
Parked
Pedestrain
Bicyclist
Other
Driving for Employer?
Yes
No
Driver's First Name
Driver's Middle Initial
Driver's Last Name
Driver's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Vehicle (Year and Make)
Vehicle License Plate or VIM
Vehicle State
Vehicle Owner's First Name
Vehicle Owner's Last Name
Vehicle Owner's Date of Birth
MM slash DD slash YYYY
Damages Over $1,000?
Yes
No
Vehicle Owner's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Insurance Company Name
Policy Number
Company NAIC Number
Policy Holder Name
Policy Start Date
MM slash DD slash YYYY
Policy Termination Date
MM slash DD slash YYYY
Injury / Property Damage
Name and Address of Individual Injured or Deceased
Status
Injured
Deceased
Role
Driver
Passenger
Bicyclist
Pedestrian
Name and Address of Individual Injured or Deceased
Status
Injured
Deceased
Role
Driver
Passenger
Bicyclist
Pedestrian
Other Property Damage
Damages Over $1,000?
Yes
No
Property Owner's First Name
Property Owner's Last Name
Property Owner's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Δ