Preliminary Traffic Accident Report Date: __________________________ Time: ____________________ (AM / PM) ___________ City:_________________ State: ______ Street name / Location _______________________________ Damage to vehicle or Property of Others: (fill in information on other driver / vehicle): Make of Vehicle:___________ Model: ___________Driver’s License number:______________________ Insurance Company: ___________________________________________________________________ Insurance Agent: ___________________________ Company or agent phone number: ______________ Name of Driver: __________________________________ Phone number: ______________________ Address of Driver: ______________________________________________________________________ List damage visible to vehicle or property:____________________________________________________ Damage to your Vehicle or property: (fill in information on your vehicle and driver): Make of Vehicle _____________ Model: ___________Drivers License Number: _____________________ Insurance Company: ____________________________________________________________________ Insurance Agent: ____________________________ Company or agent phone number: _______________ Name of Driver: __________________________________ Phone number: ________________________ Address of Driver: ______________________________________________________________________ List Damage visible to your vehicle: ________________________________________________________ Injured Person(s): 1.Name: ___________________________________ Phone Number: __________________________ Address: _________________________________________________________________________ 2.Name: ____________________________________ Phone Number: _________________________ Address: _________________________________________________________________________ 3.Name: ___________________________________ Phone Number: _________________________ Address: _________________________________________________________________________

Preliminary Traffic Accident Report (page 2) Witnesses: 1.Name: ___________________________________ Phone Number: __________________________ Address: _________________________________________________________________________ 2.Name: ____________________________________ Phone Number: _________________________ Address: _________________________________________________________________________ 3.Name: ___________________________________ Phone Number: _________________________ Address: _________________________________________________________________________ Was a police report made? Yes No Name of Department: __________________________________________________________________ Was anyone cited or arrested? Yes No Names: _________________________________ Charges: ___________________________________ Brief narrative of accident: _____________________________________________________________________________________

Preliminary Traffic Accident Report (page 3) Diagram of accident (show location and direction of travel of all vehicles, street names, skid marks, signs etc.