THE OTHER DRIVER AND CAR

Name of other driver _________________________________

Street address __________________________________

City __________________________________

State __________________________________

Vehicle registration
(car license)number __________________________________
Make and type of car ________________ Year __________

Number of driver's license of other driver __________________

Has other driver apparently been drinking? __________________________________

Any verbal statement made by other driver as to cause of accident: _________________________________

NAMES AND ADDRESSES OF PASSENGERS IN OTHER CAR

Name __________________________________

Address __________________________________

Name __________________________________

Address __________________________________

Name __________________________________

Address __________________________________

NAME AND ADDRESSES OF ALL POSSIBLE WITNESSES TO ANY FACT

Name __________________________________

Address __________________________________

Name __________________________________

Address __________________________________

Name __________________________________

Address __________________________________

SPECIAL CONDITIONS TO NOTE IMMEDIATELY FOLLOWING ACCIDENT

Position of your car after accident __________________________________

Position of other car after accident __________________________________

Location of any tire marks, blood, broken glass, dirt, etc., on road or side of road __________________________________

Location of point of impact in relation to center of road or some physical object __________________________________

Did your car skid? If so, how many feet? _______________________________

Did other car skid? If so, how many feet? __________________________________

Road conditions __________________________________

Traffic conditions __________________________________

Weather conditions __________________________________

Traffic controls (traffic lights, stop signs, etc.) __________________________________

Place and extent of impact on other car __________________________________

Name and address of any wrecker that removes other car __________________________________

Other conditions that might have bearing on accident __________________________________

THE FOLLOWING MAY BE FILLED OUT EITHER AT THE SCENE OR SHORTLY AFTER LEAVING THE SCENE

Date of accident__________________________________

Time __________________________________

Location of accident __________________________________

Type of road (grade, curve, etc.) __________________________________

Speed of your car just before accident __________________________________

Speed of other car just before accident __________________________________

Direction of your car __________________________________

Direction of other car __________________________________

Were you or other driver turning? __________________________________

Did other driver signal properly (with arm, horn, lights, etc.)? __________________________________

If at night, were his lights turned on? __________________________________

How far were you from the other car when you first saw it? __________________________________

Other pertinent facts? __________________________________