Motor Vehicle Accident Report Template
[Your Full Name]
[Street Address]
[City, State/Province, ZIP/Postal Code]
[Phone Number]
[Email Address]
Date of Birth: [MM/DD/YYYY]
1. Basic Accident Information
Accident Date: [MM/DD/YYYY]
Accident Time: [HH:MM a.m./p.m.]
Accident Location (Street Address / Intersection / Mile Marker): [Location Description]
City: [City]
State/Province: [State/Province]
County (if applicable): [County]
Type of Road: [Highway / City Street / Rural Road / Parking Lot / Other]
Road Direction(s): [e.g., “Northbound / Southbound”]
Weather Conditions at Time of Accident: [Clear / Rain / Snow / Fog / Other]
Lighting Conditions: [Daylight / Dawn / Dusk / Dark – Streetlights / Dark – No Streetlights]
Road Surface: [Dry / Wet / Icy / Snowy / Gravel / Other]
2. Your Vehicle and Driver Information
Driver Name: [Your Full Name]
Driver’s License Number and State/Province: [License No., State/Province]
Vehicle Owner (if different): [Owner Name]
Vehicle Year, Make, Model: [Year, Make, Model]
Vehicle Color: [Color]
License Plate Number and State/Province: [Plate, State/Province]
Insurance Company: [Insurance Company Name]
Policy Number: [Policy Number]
Insurance Company Phone: [Phone Number]
3. Other Vehicle and Driver Information
Vehicle 2
Driver Name: [Driver’s Full Name]
Driver’s License Number and State/Province: [License No., State/Province]
Vehicle Owner (if different): [Owner Name]
Vehicle Year, Make, Model: [Year, Make, Model]
Vehicle Color: [Color]
License Plate Number and State/Province: [Plate, State/Province]
Insurance Company: [Insurance Company Name]
Policy Number: [Policy Number]
Insurance Company Phone: [Phone Number]
[If more than two vehicles were involved, copy this section and label as “Vehicle 3,” “Vehicle 4,” etc.]
4. Occupants and Injuries
Occupants in Your Vehicle
Name: [Name] – Seat Position: [Driver / Front Passenger / Rear Left / Rear Center / Rear Right / Other]
Injury: [None / Minor / Serious] – Description: [Brief description or “N/A”]
Name: [Name] – Seat Position: [Seat Position]
Injury: [None / Minor / Serious] – Description: [Brief description]
[Add additional lines as needed.]
Occupants in Other Vehicle(s)
Vehicle 2 Occupants:
Name: [Name] – Seat Position: [Seat Position]
Injury: [None / Minor / Serious] – Description: [Brief description]
Name: [Name] – Seat Position: [Seat Position]
Injury: [None / Minor / Serious] – Description: [Brief description]
[Add additional lines and repeat for each vehicle, as needed.]
5. Property Damage
Damage to Your Vehicle:
Area(s) of Impact: [e.g., “Front left,” “Rear bumper,” “Passenger side”]
Visible Damage Description: [Crushed, dented, broken glass, deployed airbags, etc.]
Whether Vehicle Was Towed: [Yes / No] – Towed To: [Tow Company Name and Location]
Damage to Other Vehicle(s):
Vehicle 2 Area(s) of Impact: [Description]
Visible Damage Description: [Description]
Other Property Damage (fences, buildings, signs, guardrails, personal property):
Description of Property: [Type and owner, if known]
Damage Description: [Brief description]
6. Detailed Description of Accident
Provide a clear, factual description of how the accident occurred. Include directions of travel, lane positions, traffic signals or signs, speeds (if known), and actions taken by each driver.
Before the collision, my vehicle was traveling [direction, lane, speed if known] on [road name]. The other vehicle was traveling [direction, lane, speed if known] on [road name].
[Describe events step by step, for example:]
[Describe approach to intersection, traffic signals, stop signs, or yield signs.]
[Describe actions such as turning, changing lanes, stopping, slowing, or accelerating.]
[Describe point of impact and how the vehicles moved immediately after impact.]
[Mention any evasive actions taken (braking, swerving) and whether horns or signals were used.]
If the accident involved parked vehicles, pedestrians, cyclists, or fixed objects, describe their position and what occurred.
7. Accident Diagram (If Needed)
Use this section to create a simple diagram of the accident scene. Show:
Road names and directions (with arrows).
Lane markings, traffic signals, stop signs, or yield signs.
Position of each vehicle before, at the moment of impact, and after the collision (labeled “V1,” “V2,” etc.).
Any relevant landmarks (driveways, intersections, medians, buildings).
[Space for diagram or note: “Diagram attached as separate page.”]
8. Witness Information
Witness 1:
Full Name: [Name]
Phone Number: [Phone Number]
Email (if known): [Email Address]
Street Address (if known): [Address]
Brief Summary of What Witness Observed (if known):
[Short description]
Witness 2:
Full Name: [Name]
Phone Number: [Phone Number]
Email (if known): [Email Address]
Street Address (if known): [Address]
Brief Summary of What Witness Observed (if known):
[Short description]
[Add additional witness sections as needed.]
9. Police, Emergency, and Citation Information
Police Agency Responding: [Agency Name – e.g., City Police, State Police, Sheriff]
Officer Name(s): [Name(s) if known]
Badge Number(s): [Number(s) if known]
Police Report Number (if available): [Report Number]
Was a Police Report Filed? [Yes / No / Unknown]
Citations Issued:
To You: [Yes / No] – If Yes, Citation(s) for: [Offense(s)]
To Other Driver(s): [Yes / No / Unknown] – If Yes/Unknown, details (if known): [Description]
Emergency Medical Response (EMS/Fire): [Yes / No]
If Yes, Agency and Actions Taken (e.g., transport to hospital, on-site treatment): [Description]
10. Insurance and Claim Information
Your Insurance Claim Number (if assigned): [Claim Number]
Adjuster Name (if known): [Name]
Adjuster Phone/Email: [Contact Information]
Other Driver’s Claim Number (if known): [Claim Number]
Related Legal or Administrative Case Numbers (if applicable):
DUI or Traffic Case No.: [Number]
Civil Case No.: [Number]
DMV or Administrative Case No.: [Number]
11. Additional Notes or Attachments
Use this section to list and briefly describe any documents, photos, or other materials attached to this report:
Photographs of vehicle damage
Photographs of accident scene
Copy of police report or incident card
Medical documentation summary or discharge instructions
Repair estimates or invoices
Other: [Description]
Additional Notes:
[Free text area for any other important details not covered above.]
12. Certification
I, [Your Full Name], certify that the information provided in this Motor Vehicle Accident Report is true and accurate to the best of my knowledge and recollection. If I later become aware of significant new information, I will update or supplement this report as needed.
Signature: _______________________________
Printed Name: [Your Full Name]
Date: [MM/DD/YYYY]
