Accident Information Form
Please print this page and keep it in your vehicle.
Compliments of: Jimmy & Son Autobody
616-620 N Cameron St.
Winchester, VA. 22601
540.665.0882
After an Accident Do
Stop see if any one was hurt
Identify yourself
Call 911
Did anyone see the accident (names)
After an Accident Don'ts
Do not discuss responsibility
Do not sign any documents (other than police if needed)
General Information
Date __________ Time ________ Weather________
Road Condition _____________ Visibility___________
Accident Location_____________________________
Anyone injured_______________________________
Damaged area of other vehicle __________________
Witness
Police officer name _______________ Badge #______
Case # __________ Other______________________
Other Persons Information
Name ______________________________________
Address____________________________________
City____________ State ________ Zip ___________
Phone # Home ___________ Work______________
DL# _____________________ DOB____________
License # _________ Color of car _______________
Make of vehicle ______________________________
Insurance Co.___________ Policy # ______________
Other ______________________________________
Accident Details
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
This form is for notes only, you may need to fill out a state or city accident form. Do's and Don't are suggestions only, please contact your
insurance agent for specifics.