EmailMeForm
Driver's Report of Motor Vehicle Accident
If you've been involved in a vehicle collision on the job, do not leave the scene until you've completed these steps:
1) Called 911
2) Given the police all the information you can
3) Exchange information with the other driver: name, address of the driver and car owner (if different), driver's license number, vehicle registration number, take a picture of the driver's insurance card or collect all the information listed.
4) Remain at the scene until police allows you to leave safely
5) Contact Karla Montgomery to report immediately. 918-995-1317
6) Complete the below information.
List your name with position you hold at Bios or A Better Life Homecare:
Were you one of the drivers involved in the accident?
Yes
No
List your address, city, state and zip:
List your phone number:
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List your address, city, state and zip:
List your driver's license number:
Please provide your vehicle type, year, make and model:
List your vehicle's identification number:
Please provide your insurance carriers name, Agent's name, phone number, policy number and dates of coverage:
Other Driver's Information
Provide all information:
List the name of the other driver:
List other driver's address including city, state and zip.
List other driver's phone number:
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List the other driver's license number:
List other driver's vehicle type, year, make and model:
List other driver's birthdate:
Please provide others driver's insurance carriers name, Agent's name, phone number, policy number and dates of coverage:
Details of Accident:
Provide all details of the accident
County accident occurred in:
City accident occurred in:
Road or Street on which accident occurred:
List nearest intersection and nearest landmark of accident location:
Date/Time accident occurred:
MM
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YYYY
HH
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MM
AM
PM
AM/PM
Number of vehicles involved in accident:
Did the police get called to investigate the accident? If so, list officer's name and case number.
Did you receive a citation at the site of the accident?
Yes
No
Both driver's did
Describe what occurred:
In your opinion, what caused the accident:
Describe in detail, what damage occurred to the vehicles involved:
Describe in detail, any damage caused by the accident to other property: (i.e. road sign, railing, etc..)
Were you wearing your seat belt?
Yes
No
Was the other driver wearing their seat belt?
Yes
No
Was anyone ejected from a vehicle? If so, please state whom was ejected:
Please list all known injuries you received:
Please list all known injuries the other driver received:
What day of the week did the accident occur on:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Additional Comments: List anything additional that needs to be known
Name of person completing this report:
First
Last
