Accident Questionaire

Name
Describe your Vehicle
CompactFull SizedMid -sizedSemi-TrailerPick-up truckOther
Make
Year
Model
Approx.speed
CompactMid-SizeFull-Size
Describe the accident:
Date of accident:

MonthDayYear
Date
Crossing an intersectionStopped at an intersectionStopped for a pedestrianStopped for trafficTraveling at posted speed limitTraveling faster than posted speed imitTurning
Hit head-onWas hit on the left frontWas hit on the right frontWas hit on the left rearWas hit on the right rearWas rear endedOther
CompleteExtensiveMinimalModerate
CompactFull sizedMid-SizedSemi-TrailerPick-up TruckOther
Make
Year
Model
Approx.speed
CompleteExtensiveMinimalModerate
ClearCloudyDrizzlingFoggyRainySnowyStormySunny
DampDryDry with patches of iceIced overSnowed overWet
Describe moment of impact
Leaning forwardSlouched down in seatStraightTurned to the leftTurned to the right
Backward then forwardForward then backwardTo the leftTo the rightOutside of the vehicleUnder the vehicle
StraightTilted forwardTurned to the leftTurned to the right
Backward then forwardForward then backwardSide to side
Lap beltShoulder beltShoulder and lap belt
DriverFront passengerBack passenger right sideBack passenger left sideBack passenger middleOther
YesNo
YesNo
If YES, name of facility:
Signature OR If under 18, guardian signature:

Clear
A.Backward then forward B.Forward then backward To the left c. D.To the right Outside of the vehicle E. F.Under the vehicle
Should be Empty:

Describe your Vehicle