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: