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 |
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| Form Name | Accident Report Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Irritability, headrest, citations, Disturbances |
ACCIDENT REPORT FORM
NAME |
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AGE |
DATE OF BIRTH |
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DATE OF ACCIDENT/INJURY |
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TIME |
LOCATION |
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Please describe how accident/injury happened:
Please describe in detail your present symptoms:
Please describe symptoms immediately following accident/injury:
EMPLOYMENT |
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Describe (if any) |
Have you lost any days of work? Please list dates. |
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Date of return to work fully. |
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Prior to the accident were you able to work on an equal |
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basis with others your age? |
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Are any of your activities restricted? |
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AUTO ACCIDENT ONLY |
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Were you aware of the oncoming accident? |
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Were you wearing a seatbelt? Type? |
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Were weather conditions a factor? Please describe. |
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Were you moving at the time of the accident? Speed? |
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If stopped, was your foot on the brake? |
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Was the other vehicle moving at the time of the accident?Speed□ |
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Were traffic citations issued? To whom? |
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Were you knocked unconscious? If so, how long? |
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Were you hospitalized? How did you get there? |
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Was your torso or head turned at the time of impact? How? |
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Did you have symptoms prior to the accident? |
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Where were you seated in the vehicle? |
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What is the cost damage to the vehicle you were in? |
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Where was the vehicle struck? |
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Please list the year, make & model of the care you were in. |
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Please list any previous auto accidents. |
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How far was the top of headrest from the top of your head? |
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Please list the year, make & model of the other vehicle. |
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Please check which car parts broke:
On what part of the car did the following body parts hit: Head: |
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Chest: |
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Lt/Rt shoulder: |
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Other: |
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For proper handling of your claim please fully complete.
Check symptoms you have noticed since Accident:
□ Headache |
□ Constipation |
□ Fainting |
□ Chest Pain |
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□ Neck Pain |
□ Diarrhea |
□ Loss of Balance |
□ Depression |
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□ Neck Stiffness |
□ Dizziness |
□ Loss of Taste |
□ Loss of Strength |
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□ Sleeplessness |
□ Nausea |
□ Loss of Smell |
□ Ringing in Ears |
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□ Mid Back Pain |
□ Head Feels Heavy |
□ Cold Hands |
□ Light Sensitivity |
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□ Low Back Pain |
□ Numbness in Legs |
□ Cold Feet |
□ Clumsiness |
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□ Arm Pain |
□ Numbness in Arms |
□ Loss of Memory |
□ Face Flushed |
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□ Leg pain |
□ Numbness in Toes |
□ Disorientation |
□ Cold Sweats |
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□ Nervousness |
□ Numbness in Fingers |
□ Unclear Thinking |
□ Upset Stomach |
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□ Tense Muscles |
□ Difficulty Breathing |
□ Visual Disturbances |
□ Fever |
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□ Irritability |
□ Fatigue |
□ Difficulty Swallowing |
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Your Auto Insurance: |
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Driver’s Auto Insurance (if different): |
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Company Name: |
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Company Name: |
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Address: |
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Address: |
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City, State, Zip: |
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City, State, Zip: |
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Company Phone Number: |
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Company Phone Number: |
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Policy Number: |
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Policy Number: |
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Claim No. (if known): |
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Claim No. (if known): |
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Your Health Insurance: |
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Other Parties Auto Insurance: |
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Company Name: |
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Company Name: |
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Address: |
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Address: |
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City, State, Zip: |
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City, State, Zip: |
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Company Phone Number: |
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Company Phone Number: |
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Policy Number: |
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Policy Number: |
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Claim No. (if known): |
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Your Attorney (If Any): |
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Doctors or Hospitals Consulted: |
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Name: |
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Name: |
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Address: |
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Address: |
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City, State, Zip: |
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City, State, Zip: |
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Phone Number: |
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Dates of Treatment: |
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Signature: |
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Date: |
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