Self-Reporting Accident Report

Date of Report

Date of Accident

Number of Vehicles Involved

Location (street address, pole number/street, mile marker, etc. where the accident occurred - be as specific as possible)

Vehicle #1 Operator Information

Name

Phone Number

Email (a copy of this form submission will be emailed to this address)

Date of Birth

Driver's License Number

Driver's License State

Vehicle #1 Owner Information

Name

M/V Registration (Plate No.)

State of M/V Registration

Make of Vehicle

Model of Vehicle

Year of Vehicle

VIN #

Insurance Company Name and Address

Policy #

Vehicle #1 Operator: Describe what happened - indicating the location of damage, extent and circumstances of the accident below

Statement

Vehicle #1 Operator: Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Vehicle #2 Operator Information (if known)

Name

Phone Number

Date of Birth

Driver's License Number

Driver's License State

Vehicle #2 Owner Information (if known)

Name

M/V Registration (Plate No.)

State of M/V Registration

Make of Vehicle

Model of Vehicle

Year of Vehicle

VIN #

Insurance Company Name and Address

Policy #

Please attach any additional information, below, as desired (you will have the ability to take photos if using a smartphone). There is a 250 MB limit per attachment.

Copy of Drivers License

Copy of Insurance Card

Picture(s) from the Scene

Diagram or Sketch

Screenshot of Location on Map

Other