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Vehicle Incident Report PDF Details

A car wreck can be a traumatic event, even if there are no serious injuries. Dealing with the aftermath can be stressful, especially if you are not sure what to do. Thankfully, there is a form template available to help you document everything related to the incident. This Vehicle Incident Report Form can help make the process easier by providing a structure for your report. The form can be used for accidents that occur on private property or public roads. Having detailed information about the accident will assist in any legal proceedings and insurance claims that may need to be filed.

The listing holds information about the vehicle incident report. There, you will find the information about the form you would like to fill in, such as the likely time required to complete it along with other details.

Question	Answer
Form Name	Vehicle Incident Report
Form Length	4 pages
Fillable?	Yes
Fillable fields	214
Avg. time to fill out	21 min 56 sec
Other names	vehicle incident online, vehicle accident report template word, printable incident reports, vehicle incident report

12

Form Preview Example

A. Crash Location

A1. City/Town Where Crash Occurred

A2. Date of Crash

A3. Time of Crash

AM

A4. # Vehicles Involved:

PM

Please complete Section A1 or A2 below to indicate the location of the crash. If you need

A5. Did the crash occur at an

Yes

No

additional space to describe the crash location, please use Section J on the last page of this form.

intersection of two or more streets?

If Yes.

Step 1. Please indicate the route or roadway where

If No.

Step 1. Please

indicate the route, roadway and address where the

you were travelling when the crash occurred:

crash occurred:

at Street or Address Number:

The crash occurred on Route #:

on the Street/Roadway known as

Route#

Name of Roadway/Street

Step 2. What was the name (or names) of the intersecting streets?

Step 2. Please provide as much of the following specific location information as possible:

The crash occurred

(indicate direction as N/S/E/W)

(estimate number of feet)

of:

a) Mile Marker number

OR: b) Exit Number

Route#

Name of Roadway/Street

OR: c) Intersecting

Route# Name of

Street/Roadway

Roadway/Street

Route#

Name of Roadway/Street

OR: d) Landmark

B. Vehicle You Were Driving

B1. Number of occupants in vehicle (including yourself):

B2. Was vehicle damage above $1000?

Yes

No

B3. Driver’s License Number

B4. License State

B5. DOB

B6. Age

B7. Sex

M

X

B8. License Class

D

A

F

U

Unknown

C

B

M

B9. Commercial Driver’s License Endorsements		P (Passenger transport)	T (Doubles/Triples)
H (Hazardous)	X (Tank and Hazardous)	N (Tank vehicles)	S School Bus
B11. Your Full Name (Last, First, Middle)		B12. Street Address	City

B10. Vehicle Travel Direction

N	S	E	W
State			Zip Code

B13. Insurance Company

B14. Vehicle Registration #

B15. Reg. Type

B16. Reg. State

B17. Vehicle Year

B18. Vehicle Make

B19. Indicate your type of vehicle		4	Bus (16 or more passengers)				9 Truck tractor (bobtail)
1	Passenger car	5	Bus (9-15 passengers)				10 Tractor/semi-trailer
2	Light truck (van, mini-van,
		6	Single-unit truck (2 axles)				11 Tractor/doubles
pick-up, sport utility)
		7	Single-unit truck (3 or more axles)				12 Tractor/triples
3	Motorcycle
		8 Truck/trailer					13 Unknown heavy truck

B20. Full Name of Vehicle Owner (Last, First, Middle)						B21. Street Address		City

14 Motor home/ recreational vehicle

15 Moped

16 Low Speed

Vehicle

State

17 All terrain vehicle( ATV)

18Snowmobile

97Other

99Unknown

Zip Code

	B22. What Was Your Vehicle Doing Prior to the Crash?			5 Changing lanes			8	Making U-turn		11 Parked
	1 Travelling straight ahead	3	Turning right	6	Entering traffic lane		9	Overtaking/passing		97 Other
	2 Slowing or stopped	4	Turning left
				7	Leaving traffic lane		10 Backing			99 Unknown


	B23. Please Indicate the Sequence of Events as they occurred to YOUR Vehicle					What happened first?	Second?		Third?	Fourth?
	by writing the corresponding number (1-52, or 97, 99) in up to 4 boxes below.

	Collision with	9	Railway vehicle	25	Median barrier	32 Crash cushion/
	1 Motor vehicle in traffic	jh	(train, engine)	26	Ditch	jh Impact attenuator
	2 Parked motor vehicle	10	Other movable object			33 Bridge
				27	Embankment/
	3 Pedestrian	11	Unknown movable	jh	Sloping shoulder	34 Bridge overhead
	4 Cyclist	jh	object	28	Highway traffic	jh structure
		20	Curb			35 Other fixed
	5 Animal- deer			jh signpost
		21	Tree	29	Overhead sign	jh object (wall,
	6 Animal- other					jh building, tunnel)
		22	Utility pole	jh	support
	7 Moped			30	Fence	36 Unknown fixed
		23	Light pole or other
	8 Work zone			31	Mailbox	object
		jh	post/support
	maintenance	24	Guardrail
	equipment

Non-Collision

40 Ran off road right

41 Ran off road left

42 Cross median/ jh centerline

43Overturn/rollover

44Equipment failure jh (blown tire, brakes, jh etc)

45Fire/explosion

46Immersion

47Jackknife

48Cargo/equipment loss jh or shift

49Separation of units

50Downhill runaway

51Other non-collision

52Unknown non-collision

97Other

99Unknown

	B24. Was your
	Vehicle Towed	Yes	No
	from the Scene	Yes	No
	from the Scene
	Due to Damage?

	B25. Vehicle Damaged Area (check up to three)		2	3	4
	B25. Vehicle Damaged Area (check up to three)
	0 None	97 Other	1	9	5
	10 Undercarriage	99 Unknown	1	9	5
	10 Undercarriage	99 Unknown
	11 Totaled		8	7	6
			8	7	6

CRASH102_1119

C. You and Your Passengers	Please provide the full name, address, and DOB or Age for all passengers in your vehicle. Then write the
C. You and Your Passengers	corresponding code in each of the boxes for each occupant of the vehicle (yourself and all passengers). A
	list of the possible codes is provided at the bottom of this section.

C1. Passenger 1 (Last, First, Middle)

C2. Address

City

State

Zip Code

C3. DOB

C4. Sex

C5. Passenger 2 (Last, First, Middle)

C6. Address

City

State

Zip Code

C7. DOB

C8. Sex

C9. Passenger 3 (Last, First, Middle)

C10. Address

City

State

Zip Code

C11. DOB

C12. Sex

Seating

Safety

Air Bag

Ejected

Transported

Name of Medical

System

From

for Medical

Position

Used

Status

Vehicle?

Trapped?

Injured?

Care?

Facility

Driver

Passenger 1

Passenger 2

Passenger 3

	Seating Position
	1	Front seat - left side (or	8	Third row - middle
		motorcycle driver)	9	Third row - right side
	2	Front seat - middle
			10	Sleeper section of cab
	3	Front seat - right side
			11	Enclosed passenger area
	4	Second seat - left side (or
			12	Unenclosed passenger area
		motorcycle passenger)
	5	Second seat - middle	13	Trailing unit
			14	Riding on vehicle exterior
	6	Second seat - right side
			97	Other
	7	Third row - left side (or

Safety System Used

0None used

1Shoulder and lap belt

2Lap belt only

3Shoulder belt only

4Child safety seat

5Helmet

97Unknown

Air Bag Status

1Deployed-front

2Deployed-side

3Deployed both front and side

4Not deployed

5Not applicable

97Unknown

	motorcycle passenger)				99 Unknown
Ejected From Vehicle?				Trapped?
0	Not ejected	3	Not	0	Not trapped	2 Freed by
1	Totally ejected	k applicable		1	Freed by	k non-mechanical
		97				d means
2	Partially ejected		Unknown		mechanical
						97 Unknown
					means

	Injured?		Transported for Medical Care?
	1	Fatal	1	Not transported	3	Police
	7	Suspected serious injury	2	EMS	97	Other
	8	Suspected minor injury	2	EMS	97	Other
	8	Suspected minor injury		(emergency	99	Unknown
	9	Possible Injury		service)	99	Unknown
	10	No apparent injury

D. Other Vehicle(s) Involved in the Crash

D1. Number of occupants

D2. Number of

D3. Was Vehicle

Yes

No

D4. Moped?

D5. Hit and Run?

in the Vehicle:

injured occupants

Damage above $1000?

Yes

No

Yes

No

D6. Driver’s License Number

D7. License State

D8. DOB

D9. Age

D10. Sex

M

X

D11. License Class

D

A

F

U

Unknown

C

B

M

D12. Commercial Driver’s License Endorsements

P (Passenger transport)

T (Doubles/Triples)

D13. Vehicle Travel Direction

H (Hazardous)

X (Tank and Hazardous)

N (Tank vehicles)

S School Bus

N

S

E

W

D14. Name of Vehicle Driver (Last, First, Middle)

D15. Street Address

City

State

Zip Code

D16. Insurance Company

D17. Vehicle Registration #

D18. Reg. Type

D19. Reg. State

D20. Vehicle Year

D21. Vehicle Make

D22. Indicate your type of vehicle

4 Bus (16 or more passengers)

9 Truck tractor (bobtail)

14 Motor home/

17 All terrain

1 Passenger car

5 Bus (9-15 passengers)

10 Tractor/semi-trailer

recreational vehicle

vehicle( ATV)

2 Light truck (van, mini-van,

15 Moped

18 Snowmobile

6 Single-unit truck (2 axles)

11 Tractor/doubles

pick-up, sport utility)

16 Low Speed

97 Other

7 Single-unit truck (3 or more axles)

12 Tractor/triples

3 Motorcycle

Vehicle

99 Unknown

8 Truck/trailer

13 Unknown heavy truck

D23. Full Name of Vehicle Owner (Last, First, Middle)

D24. Street Address

City

State

Zip Code

D25. What Was Your Vehicle Doing Prior to the Crash?

D26. Vehicle Damaged Area (check up to three)

0 None

1 Travelling straight

5 Changing lanes

9 Overtaking/passing

2

3

4

10 Undercarriage

ahead

6 Entering traffic lane

10 Backing

2 Slowing or stopped

11 Totaled

7 Leaving traffic lane

11 Parked

1

9

5

3 Turning right

97 Other

8 Making U-turn

97 Other

4 Turning left

8

7

6

99 Unknown

99 Unknown

CRASH102_1119

E. Non-Motorist(s) Involved in the Crash

E1. Indicate the type of non-motorist involved

1 Pedestrian

2 Cyclist

3 Skater

97 Other

99 Unknown

E2. What was the non-motorist doing prior to the crash?

E3. Where was the non-motorist prior to the crash?

1 Entering or crossing

4

Pushing vehicle

97 Other

1 Marked crosswalk

4

In roadway

8

Shoulder

location

5

Approaching or

99 Unknown

at intersection

5

Not in roadway

9

Sidewalk

2 Walking, running, or

2 At intersection but

leaving vehicle

6

Median (but not on

10

Shared-use

cycling

6

Working on vehicle

no crosswalk

shoulder)

path or trails

3 Working

3 Non-intersection

7 Standing

7

Island

99

Unknown

crosswalk

E4. Full Name of Non-Motorist (Last, First, Middle)

E5. Street Address

City

State Zip Code

E6. DOB

E7. Sex

E8. Safety Equipment?

8

Reflective clothing

E9. Injured?

8

Suspected

10 No

E10. Transported for Medical Care?

0 None used

9

Lighting

1 Fatal

1 Not transported

3

Police

6 Helmet

7 Suspected

g

minor injury

apparent

2 EMS (emergency

97 Other

10

Other

9

Possible

injury

7 Protective pads

serious

service)

99 Unknown

99

Unknown

injury

Injury

(elbows, knees, etc.)

E11. If transported, please indicate Hospital/Medical Facility:

F. Crash Conditions

F1. Light Conditions	97Other
1 Daylight	97Other
2 Dawn	99Unknown
3 Dusk
4 Dark - lighted
roadway

5 Dark - roadway not lighted

6 Dark - unknown roadway lighting

F2. Weather Conditions (up to two)

	1 Clear	7 Severe
	2 Cloudy	crosswinds
	2 Cloudy	8 Blowing
	3 Rain	8 Blowing
	3 Rain	sand, snow
	4 Snow	sand, snow
	4 Snow	97 Other
	5 Sleet, hail,	97 Other
	5 Sleet, hail,	99 Unknown
	freezing	99 Unknown
	freezing
	rain
	6 Fog, smog,
	smoke

F3. Traffic Control Device

1 No controls

2 Stop signs

3 Traffic control signal

4 Flashing traffic control signal

5 Yield signs

6 School zone signs

7 Warning signs

8 Railroad crossing device

99 Unknown

F4. Road Surface

1 Dry

2 Wet

3 Snow

4 Ice

5 Sand, mud, dirt, oil, gravel

6 Water (standing, moving)

7 Slush

97 Other

99 Unknown

F5. Trafficway Description

F6. Manner of Collision

6 Head on

F7. Roadway Intersection Type

1 Two-way, not divided

1 Single vehicle crash

1 Not at intersection

7 Traffic circle

2 Two-way, divided, unprotected median

2 Rear-end

7 Rear to rear

2 Four-way intersection

8 Five-point or more

3 Two-way, divided, protected median

3 Angle

99 Unknown

3 T-intersection

9 Driveway

4 One-way, not divided

4 Sideswipe, same

4 Y-intersection

10 Railway grade

99 Unknown

direction

5 On ramp

crossing

5 Sideswipe, opposite

99 Unknown

6 Off ramp

direction

F8. Was the traffic control device

Yes

No

F9. School Bus Related?

Yes

No

F10. Work Zone Related?

Yes

No

functioning at the time of the crash?

G. Crash Diagram

Indicate

North by

Arrow

Please draw a diagram of the

roadway or streets where the

crash occurred, indicating the

vehicles involved and direction of

travel using the following symbols:

Direction

= Vehicle 1 (Your Vehicle)

1

= Vehicle 2

2

= Pedestrian/Non-motorist

= North

Select one of the following if the

crash did not occur on a public

way:

Off-street parking lot

Garage

Mall/shopping center

Other private way

CRASH102_1119

H. Witness Information

H1. Witness Name (Last, First, Middle)	H2. Street Address	City	State	Zip Code	H3. Phone
H4. Witness Name (Last, First, Middle)	H5. Street Address	City	State	Zip Code	H6. Phone

I. Property Damage Information (Other than Vehicles)

I1.	Owner Name (Last, First, Middle)	I2. Street Address	I3. Phone	I4.	Property and Damage Description

I5.	Owner Name (Last, First, Middle)	I6. Street Address	I7. Phone	I8.	Property and Damage Description

J.	Description of What Happened

K. Signature

“Signed under Pains and Penalties of Perjury”		Print		Date

CRASH102_1119

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Step 1: The very first step will be to select the orange "Get Form Now" button.

Step 2: Now, you are on the document editing page. You may add content, edit current information, highlight specific words or phrases, put crosses or checks, insert images, sign the document, erase unneeded fields, etc.

If you want to prepare the document, provide the data the program will request you to for each of the following parts:

part 1 to completing vehicle incident report online

Fill in the Zip, Code Parked, Other, Unknown, Fourth B, Indicate, your, type, of, vehicle B, Street, Address State, Turning, right, Turning, left Making, U, turnOver, taking, passing, Backing What, happened, first Second, Third, j, hj, hj, h j, hj, hj, h NonCollisionj, hj, hj, h and B, Vehicle, Damaged, Area, checkup, to, three areas with any content which may be asked by the system.

stage 2 to completing vehicle incident report online

Jot down the crucial particulars in Yes, None, Undercarriage, Totaled Other, Unknown and CRASH part.

Entering details in vehicle incident report online step 3

The C, Passenger, Last, First, Middle C, Address C, Passenger, Last, First, Middle C, Address C, Passenger, Last, First, Middle C, Address City, City, City, State, Zip, Code C, DOB C, Sex State, and Zip, Code space is where all sides can describe their rights and obligations.

Filling in vehicle incident report online part 4

Look at the fields D, License, StateD, DOB D, Was, Vehicle, Damage, above Yes, D, Moped D, Hit, and, Run Yes, Yes, D, AgeD, Sex D, License, Class, C Unknown, H, Hazardous P, Passenger, transport, N, Tank, vehicles T, Double, sTrip, lesS, School, Bus D, Street, Address and City and next fill them in.

vehicle incident report online DLicenseStateDDOB, DWasVehicleDamageabove, Yes, DMoped, DHitandRun, Yes, Yes, DAgeDSex, DLicenseClassC, Unknown, HHazardous, PPassengertransportNTankvehicles, TDoublesTriplesSSchoolBus, DStreetAddress, and City blanks to complete

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