Accident Report Form – Fill Out and Use This PDF

Accident Report Form is a document used by an individual or organization to report an accident. It includes information such as the time, location, details of the event and other pertinent data.

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Accident Report Form PDF Details

In order to document an accident, it is necessary to fill out an accident report form. The purpose of this form is to gather information about the accident so that it can be analyzed and used to improve safety conditions. There are many different types of accident report forms, so it is important to know which one needs to be filled out for the particular accident. The form must be filled out as accurately as possible, and should include information such as the date and time of the accident, the location, who was involved, and what happened. A thorough description of the accident is also required. Any pictures or videos taken at the scene should be included as well. Once the form has been completed, it should be submitted to a supervisor for review.

You can find details about the type of form you want to submit in the table. It can show you the span of time you will need to finish accident report form, what parts you will have to fill in, and so forth.

Question	Answer
Form Name	Accident Report Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	170
Avg. time to fill out	34 min 34 sec
Other names	Stiffness, Irritability, slip and fall intake form, Numbness

12

Form Preview Example

ACCIDENT REPORT FORM

NAME				AGE			DATE OF BIRTH

DATE OF ACCIDENT/INJURY			TIME				LOCATION

Please describe how accident/injury happened:

Please describe in detail your present symptoms:

Please describe symptoms immediately following accident/injury:

EMPLOYMENT	Yes	No	Describe (if any)
Have you lost any days of work? Please list dates.	□	□
Date of return to work fully.	□	□
Prior to the accident were you able to work on an equal	□	□
basis with others your age?	□	□
Are any of your activities restricted?	□	□
AUTO ACCIDENT ONLY	□	□
Were you aware of the oncoming accident?	□	□
Were you wearing a seatbelt? Type?	□	□
Were weather conditions a factor? Please describe.	□	□
Were you moving at the time of the accident? Speed?	□	□
If stopped, was your foot on the brake?	□	□
Was the other vehicle moving at the time of the accident?Speed□		□
Were traffic citations issued? To whom?	□	□
Were you knocked unconscious? If so, how long?	□	□
Were you hospitalized? How did you get there?	□	□
Was your torso or head turned at the time of impact? How?	□	□
Did you have symptoms prior to the accident?	□	□
Where were you seated in the vehicle?	□	□
What is the cost damage to the vehicle you were in?	□	□
Where was the vehicle struck?	□	□
Please list the year, make & model of the care you were in.	□	□
Please list any previous auto accidents.	□	□
How far was the top of headrest from the top of your head?	□	□
Please list the year, make & model of the other vehicle.	□	□

Please check which car parts broke: □Rt-Lt side windows □Windshield □Steering wheel □Front/back seat

On what part of the car did the following body parts hit: Head:									Chest:
Lt/Rt shoulder:			Lt-Rt arm:			Lt-Rt hip:

Lt-Rt leg:			Lt-Rt knee:			Other:

For proper handling of your claim please fully complete.

Check symptoms you have noticed since Accident:

□ Headache

□ Constipation

□ Fainting

□ Chest Pain

□ Neck Pain

□ Diarrhea

□ Loss of Balance

□ Depression

□ Neck Stiffness

□ Dizziness

□ Loss of Taste

□ Loss of Strength

□ Sleeplessness

□ Nausea

□ Loss of Smell

□ Ringing in Ears

□ Mid Back Pain

□ Head Feels Heavy

□ Cold Hands

□ Light Sensitivity

□ Low Back Pain

□ Numbness in Legs

□ Cold Feet

□ Clumsiness

□ Arm Pain

□ Numbness in Arms

□ Loss of Memory

□ Face Flushed

□ Leg pain

□ Numbness in Toes

□ Disorientation

□ Cold Sweats

□ Nervousness

□ Numbness in Fingers

□ Unclear Thinking

□ Upset Stomach

□ Tense Muscles

□ Difficulty Breathing

□ Visual Disturbances

□ Fever

□ Irritability

□ Fatigue

□ Difficulty Swallowing

□

Your Auto Insurance:

Driver’s Auto Insurance (if different):

Company Name:

Company Name:

Address:

Address:

City, State, Zip:

City, State, Zip:

Company Phone Number:

Company Phone Number:

Policy Number:

Policy Number:

Claim No. (if known):

Claim No. (if known):

Your Health Insurance:

Other Parties Auto Insurance:

Company Name:

Company Name:

Address:

Address:

City, State, Zip:

City, State, Zip:

Company Phone Number:

Company Phone Number:

Policy Number:

Policy Number:

Claim No. (if known):

Your Attorney (If Any):

Doctors or Hospitals Consulted:

Name:

Name:

Address:

Address:

City, State, Zip:

City, State, Zip:

Phone Number:

Dates of Treatment:

Signature:

Date:

How to Edit Accident Report Form Online for Free

Filling in Numbness is a snap. Our team designed our tool to really make it simple to use and allow you to complete any form online. Here are a few steps you will want to follow:

Step 1: First, click the orange button "Get Form Now".

Step 2: Now it's easy to alter your Numbness. This multifunctional toolbar permits you to include, erase, transform, and highlight content or perform similar commands.

Please provide the following information to create the Numbness PDF:

Stiffness empty fields to consider

Enter the appropriate information in Were you wearing a seat, belt If stopped, Were you aware of the oncoming, Were weather conditions a factor, Were you moving at the time of the, Are any of your activities, Date of return to work fully, □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □, Were you knocked unconscious, Were you hospitalized, Did you have symptoms prior to the, Were traffic citations issued, and Where were you seated in the segment.

Filling in Stiffness part 2

Write down all details you may need in the area □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □, Please list the year, What is the cost damage to the, Please list any previous auto, and Where was the vehicle struck.

Stiffness □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □, Please list the year, What is the cost damage to the, Please list any previous auto, and Where was the vehicle struck blanks to complete

The Please check which car parts, Lt, Rt hip: Other:, Chest:, On what part of the car did the, Lt, Rt arm: Lt, Rt knee:, □ Headache □ Neck Pain □ Neck, □ Fainting □ Loss of Balance □, □ Constipation □ Diarrhea □, and □ Chest Pain □ Depression □ Loss area needs to be applied to put down the rights or obligations of both parties.

stage 4 to finishing Stiffness

End by checking the following sections and writing the proper data: □ Headache □ Neck Pain □ Neck, □ Constipation □ Diarrhea □, □ Chest Pain □ Depression □ Loss, Your Auto Insurance: Company Name:, Driver, s Auto Insurance (if, Other Parties Auto Insurance:, and Doctors or Hospitals Consulted:.

Stiffness □ Headache □ Neck Pain □ Neck, □ Constipation □ Diarrhea □, □ Chest Pain □ Depression □ Loss, Your Auto Insurance: Company Name:, Driver’s Auto Insurance (if, Other Parties Auto Insurance:, and Doctors or Hospitals Consulted: blanks to insert

Step 3: If you are done, select the "Done" button to export the PDF file.

Step 4: You can generate duplicates of your file toremain away from all of the possible worries. Don't be concerned, we cannot publish or watch your data.

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