Vehicle Accident Report

CONFIDENTIAL REPORT

This report is confidential and is intended to be submitted to SMCSIG's claims administrator and district's legal counsel for use in recovering losses and defending litigation.

Date and Time of Accident

Month

Day

Year

Time

HoursMinutes

Location of Accident

District Name

Department

Vehicle Year

Vehicle Make

District Driver First Name

District Driver Last Name

Business Phone Number

Driver's License Number

For what purpose was the vehicle used?

Damage to District Vehicle

Other Driver Information

First Name

Last Name

Address

Home Phone

Business Phone

Vehicle Owner Information

First Name

Last Name

Address

Home Phone

Business Phone

Description of Vehicle Damage

Vehicle Make

Vehicle Year

Vehicle License Plate

Vehicle Registered State

Is the vehicle insured?

Injury Report

Please provide information of the injured person(s) involved in the accident.

First Name

Last Name

Phone

Age

Description of Injury

Pedestrian

Other Vehicle

District Vehicle

Witness Report

Please provide information of the witness or passenger involved in the accident.

First Name

Last Name

Phone

Age

Pedestrian

Other Vehicle

District Vehicle

Please provide a complete description of the accident

Reported To

Date

Signature

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