Wisconsin Accident Form – Fill Out and Use This PDF

Clear Form

WISCONSIN

DRIVER REPORT

CONTINUE ONLY ...if there was $1000 or more damage to any one person’s property,

OF ACCIDENT

OR ...if anyone was injured,

OR ...if there was $200 or more damage to government property, other than vehicles.

(See instructions on reverse side

before completing – Please Print)

Hit and Run Accident?

ACCIDENT

County of

City, Village or Township of

ACCIDENT Month

Day

Year

Day of Week

Time

 a.m.

 YES

DATE

 p.m.

Total Units Involved

Total Injured *

LOCATION

Name and Number of Street(s) or Highway or Parking Lot

TYPE OF

(Please check one)

 Hit another motor

 Hit a parked vehicle

 Hit a deer

 Hit a bicyclist

 Other

ACCIDENT

1 vehicle in operation

2

3

4/5 or pedestrian

9

U Driver Full Name (Last, First, MI)

Sex

U Driver Full Name (Last, First, MI)

Sex

NI

NI

Address

Birth Date

Address

Birth Date

T

T

City, State

ZIP Code

Daytime Telephone Number

City, State

ZIP Code

Daytime Telephone Number

(

)

(

)

1 Driver License Number

Issuing State

2 Driver License Number

Issuing State

Vehicle Legally Parked

Operating a commercial vehicle?

If yes, check

Vehicle Legally Parked

Operating a commercial vehicle?

If yes, check

 YES

 YES

appropriate classification

 YES

 YES

appropriate classification

 A  B  C

 A  B  C

Owner Full Name (Last, First, MI)

Owner Full Name (Last, First, MI)

Address

Address

City, State

ZIP Code

Daytime Telephone Number

City, State

ZIP Code

Daytime Telephone Number

(

)

(

)

License Plate Number

Exp Yr

Issuing State

Vehicle Make

Year

Color

License Plate Number

Exp Yr

Issuing State

Vehicle Make

Year

Color

Vehicle Identification Number

Vehicle Identification Number

Was a motor vehicle liability insurance policy

Policy Holder’s Name

Was a motor vehicle liability insurance policy

Policy Holder’s Name

in effect on the day of the accident?

in effect on the day of the accident?

 YES  NO

 YES

 NO

Exact Name of Insurance Company

Exact Name of Insurance Company

*INJURED Important:

Number of injuries reported must equal number entered in “Total Injured” box above.

For additional injuries, provide the information on a separate piece of paper and attach. Injury Codes: A=Severe, B=Moderate, C=Minor

Unit No.

Name (Last, First, MI)

Address

City, State

ZIP Code

Sex

Birth Date

Injury Code

Unit No.

Name (Last, First, MI)

Address

City, State

ZIP Code

Sex

Birth Date

Injury Code

VEHICLE Unit 1 Important: Circle the numbers closest to the damaged areas.

Unit 2 Important: Circle the numbers closest to the damaged areas.

DAMAGE Damage Estimate

6

7

8

Damage Estimate

6

7

8

(Required)

5

<![endif]>REAR

<![endif]>FRONT

1

(If Known)

5

<![endif]>REAR

<![endif]>FRONT

1

$______________

$______________

4

3

2

4

3

2

PROPERTY Describe what was damaged. Property damage includes structures, trees, fences, towed items, etc. Do NOT include vehicle damage.

DAMAGE

Property Owner Full Name (Last, First, MI)

Address

City, State

ZIP Code

Daytime Telephone Number

(

)

NARRATIVE Print a brief description of the accident.

DIAGRAM Draw a basic picture of

Indicate NORTH by putting

the accident and location.

an arrow in the circle.