| Date and time of the accident: |
|
| Where did the accident occur? |
|
|
|
| Who is the owner of the vehicle? |
|
| Is the vehicle insured? |
Yes
No |
| Did the police arrive on the scene? |
Yes
No |
Do you have a copy of the police
report? |
Yes
No |
Were there any citations or
arrests made? |
Yes
No |
|
Do you believe alcohol was a
factor in the accident? |
Yes
No |
|
| Were you injured in the accident? |
Yes
No |
|
Was the driver of the other
vehicle injured? |
Yes
No |
| Were any passengers injured? |
Yes
No |
|