| Accident Report Form | ||||||||||
| Get These Facts Date __________________________________ Time ___________________________________ Location _______________________________ City ____________________________________ Driving which direction _____________________ Which side of street ______________________ At intersection ___ Between blocks ___ Were your lights on? ___ Weather condition _________________________ Street condition ________________________ Insurance Co. _____________________________ Policy No.______________________________ Other driver's name_______________________________________________________________ Address ________________________________________________________________________ License No. ______________________________ Phone _________________________________ Witnesses Names Officer present _______________________________________ Witness name _______________________________________ Phone ______________________ Address __________________________________________ City _________________ State ____ Witness name _______________________________________ Phone ______________________ Address __________________________________________ City _________________ State ____ Witness name _______________________________________ Phone ______________________ Address __________________________________________ City _________________ State ____ List of Injured Name of Injured ______________________________________ Phone ______________________ Address __________________________________________ City _________________ State ____ Nature of Injuries _________________________________________________________________ Hospital ____________________ Home ___________________ Physician ____________________ Name of Injured ______________________________________ Phone ______________________ Address __________________________________________ City _________________ State ____ Nature of Injuries _________________________________________________________________ Hospital ____________________ Home ___________________ Physician ____________________ Name of Injured ______________________________________ Phone ______________________ Address __________________________________________ City _________________ State ____ Nature of Injuries _________________________________________________________________ Hospital ____________________ Home ___________________ Physician ____________________ Property Damage Name of Owner _______________________________________ License No. __________________ Address _____________________________________________ Phone ______________________ Describe _________________________________________________________________________ ________________________________________________________________________________ Draw a Diagram of Accident Showing the direction of both cars and the point of accident. Show street names and location of street signs (stop signs, etc.) |
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Seattle
206.728.8866 |
Bellevue
425.452.8941 |
Everett/Lynnwood/Snohomish
425.741.8633 |
South King County
253.852.7538 |
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