 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
Accident Form
Accident Information Form
- Calm Victims Handle Emergencies Better
- Do Not Leave the Scene of the Accident
- Call the Police
- Exchange Information with the Other Drivers
Police: What Department: _______________________________________ Name of Officer: __________________ Badge #: ___________ Accident Report Number: ________________________________
Important Accident Information
& Special Conditions:
Date: ___________________ Time: ____________ a.m./p.m. Weather Condition: _____________________________________ Traffic Condition: _____________________________________ Road Condition: ________________________________________ Type of Road: __________________________________________ (Grade, Curve, 4 Lane, Paved, etc.) Traffic Controls: ______________________________________ (Traffic Lights, Stop Signs, Left Turn Only Arrows, etc.) Direction of Travel: Yours: ___________ Other Drivers (1): __________________ Other Drivers (2): ________ Other Drivers (3) __________ Speed of Cars Immediately Prior to Impact: Yours: ___________ Other Drivers (1): __________________ Other Drivers (2): ________ Other Drivers (3) __________ Position of Cars after Impact: Yours: ___________ Other Drivers (1): __________________ Other Drivers (2): ________ Other Drivers (3) __________ Skid Marks - Length (in feet)/Before Impact: Yours: ___________ Other Drivers (1): __________________ Other Drivers (2): ________ Other Drivers (3) __________ Skid Marks - Length (in feet)/After Impact: Yours: ___________ Other Drivers (1): __________________ Other Drivers (2): ________ Other Drivers (3) __________ Place of Impact on vehicles: Yours: ___________ Other Drivers (1): __________________ Other Drivers (2): ________ Other Drivers (3) __________ At Night: Lights on?: Yours: ___________ Other Drivers (1): __________________ Other Drivers (2): ________ Other Drivers (3) __________ How far away were the other cars when you first saw them? Other Driver (1): ________ Driver (2): _______ Driver (3) _________ Driver - Your Car: Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Driver's License No: ___________________________________ Driver's Insurance Co.: ________________________________ Policy Number: _________________________________________ Your Car: Year: ____________ Make: ____________ Model: ___________ Color: ________________ License Tag No: ________________ Owner if not the Driver: Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Driver's License No: ___________________________________ Driver's Insurance Co.: ________________________________ Policy Number: _________________________________________ Passengers - Your Car: Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Witnesses: Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ The Other Driver (1): Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Driver's License No: ___________________________________ Driver's Insurance Co.: ________________________________ Policy Number: _________________________________________ The Other Car (1): Year: ____________ Make: ____________ Model: ___________ Color: ________________ License Tag No: ________________ Owner if not the Driver (1): Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Driver's License No: ___________________________________ Driver's Insurance Co.: ________________________________ Policy Number: _________________________________________ Passengers - Other Car (1): Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ The Other Driver (2): Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Driver's License No: ___________________________________ Driver's Insurance Co.: ________________________________ Policy Number: _________________________________________ The Other Car (2): Year: ____________ Make: ____________ Model: ___________ Color: ________________ License Tag No: ________________ Owner if not the Driver (2): Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Driver's License No: ___________________________________ Driver's Insurance Co.: ________________________________ Policy Number: _________________________________________ Passengers - Other Car (2): Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ The Other Driver (3): Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Driver's License No: ___________________________________ Driver's Insurance Co.: ________________________________ Policy Number: _________________________________________ The Other Car (3): Year: ____________ Make: ____________ Model: ___________ Color: ________________ License Tag No: ________________ Owner if not the Driver (3): Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Driver's License No: ___________________________________ Driver's Insurance Co.: ________________________________ Policy Number: _________________________________________ Passengers - Other Car (3): Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________ Name: __________________________________________________ Address: _______________________________________________ City: _______________________ State: ____ Zip: _________ Phone: (H) ______________________ (W) __________________
Accident Diagram:
Show Point of Impact:
We will mail a copy of this brochure to you. Simply email your request to us.
If you are in an accident, call an attorney to discuss your claim.
I do not charge Personal Injury Victims to discuss the merits of their case. I handle Personal Injury cases on a Contingent Fee basis. A fee is contingent when it is conditioned upon your attorney?s successfully resolution of your case, which is often referred to as: "No fee unless you win." However, the client is generally responsible for the "out-of-pocket" costs of litigation. A Contingent Fee is paid as a percentage of your monetary recovery (either settlement or court award).
David Danda
David E. Danda, PC
P. O. Box 941334
Atlanta GA 31141-0334
770.938.0977
770.939.6538 (fax)
ddanda@attbi.com (email)
| The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation. | ||
| Copyright © 2000 by David E. Danda, PC. All rights reserved. | ||
| You may reproduce materials available at this site for your own personal use and for non-commercial distribution. All copies must include the above copyright notice. | ||
|
This FirmSite® is designed and hosted by West Legal Directory, a service of West Group, Eagan, Minnesota. | |