Means Gillis Law, PC

We are providing this form as a means of organizing key information in case of a car accident. Please keep a copy of this in your car and share with your family and friends.

For a Free Consultation Call: 1 (800) 626-9684

ACCIDENT INFORMATION

Date:

Time:                 am/pm

Location of Accident:

Road Conditions:

Traffic Conditions:

Weather Conditions:

Speed of your car just before accident:

Speed of other car just before accident:

Did your car skid? If so, how many feet?

Did other car skid? If so, how many feet?

Place of impact on other car:

Any other conditions or vehicles that may have caused the accident:

OTHER DRIVER:

Name:

Address:

City/County/State:

Home Phone: Work Phone: Cellular Phone:

State: Driver’s License #: License Plate #:

Year of Car:

Make of Car:

Model of Car:

Color of Car:

Insurance Company Agent Name Policy #

Does driver appear to have been drinking? Talking on the phone?

Any statement by other driver as to cause of accident?

Any Passengers:

INVESTIGATING OFFICER

Name:

Badge #:

Agency:

City/County/State:

ANYONE TAKE PHOTOS? WHO?

WITNESS:

Name:

Address:

City/County/State:

Home Phone: Work Phone:

WITNESS:

Name:

Address:

City/County/State:

Home Phone: Work Phone:

WITNESS:

Name:

Address:

City/County/State:

Home Phone: Work Phone:

Take pictures of the scene. Get contact information of any witnesses on the scene.

 ANY OTHER NOTES: