Accident Report

704-579-5677 contact@elelogistics.com

Date of Accident*
MM slash DD slash YYYY
Time of Accident*
: Hours
Minutes
City & State Where Accident Occurred*
City State
EXACT LOCATION WHERE THE ACCIDENT OCCURRED
Nearest Intersection*
Mile Marker*
Direction of Travel (All Vehicles)*
If Private Property Describe the Facility
EXACT DESCRIPTION OF THE EVENT
Upload Pictures of the Accident
Drop files here or
Max. file size: 256 MB.
Your Vehicle is Always Vehicle Number One, Describe Events Concerning the Collision*
OFFICER'S INFORMATION
Officer's Name
First Last
Officer's Badge Number*
Local Officer or State Trooper*
- Local Officer
- State Trooper
Where is the Officer From?
Accident Report Number*
Phone Number for the Station
IF CITATIONS ISSUED
Who Received the Citation?*
What are the Charges?*
OTHER VEHICLE AND DRIVER
Full Name of the Vehicle Owner*
First Last
Owner Address*
Street Address City State ZIP Code
License Number*
Year / Make / Model of Vehicle*
Home Phone*
Work Phone*
Was the Vehicle Owner also the Driver?*
- YES
- NO
Full Name of the Driver
First Last
Driver Address
Street Address City State ZIP Code
State & License Number
Home Phone
Work Phone
Name of Insurance Company
Phone Number of Insurance Company
WITNESSES
Witness 1 name
Witness 1 phone number
Witness 2 name
Witness 2 phone number
INJURIES
Identify ALL Injured Persons
Were they Treated at the Scene and Released?
- YES
- NO
Were they Removed by Ambulance?
- YES
- NO
Name of Ambulance and Hospital
POINTS OF IMPACT
Your Vehicle*
Other Vehicle*
Damage to Your Vehicle*
Damage to Other Vehicle*
ROAD AND WEATHER CONDITIONS
Conditions 1*
- CLEAR
- RAINING
- FOGGY
- SNOWING
- OTHER
Choose all the apply
Conditions 2*
- DRY
- WET
- ICE
- OTHER
Choose all the apply
Conditions 3*
- DAYLIGHT
- DARK
- DAWN
- ARTIFICIAL LIGHT
- OTHER
Choose all the apply
If OTHER was Selected, Please Explain
Number of Lanes Both Directions*
What was your Traveling Speed?*
Estimated Speed of the Other Vehicle?*
Road Description*
- STRAIGHT
- LEVEL
- HILL
- CURVE
- OTHER
If OTHER was Selected for Road Description, Please Explain
OTHER INFORMATION
Were you Wearing a Seat Belt?*
- YES
- NO
Was the Other Driver Wearing a Seat Belt?*
- YES
- NO
- NOT SURE
Were there any Mechanical Defects that may have Caused this Event?
Were any Vehicles Towed from the Scene?*
- YES
- NO
Were was the Vehicle Towed?
In your own words, give a complete description of the accident. Tell us what happened and what you were doing just prior to the accident happening, and what actions were immediately taken after the accident. Be specific.
YOUR INFORMATION AND SIGNATURE
Your Name*
First Last
Your Statement*
I agree to the statement below.
All the information that I have provided in this form is the truth to the best of my knowledge.
Digital Signature*
Type your full name in the box to digitally sign your accident report.
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EXACT LOCATION WHERE THE ACCIDENT OCCURRED

EXACT DESCRIPTION OF THE EVENT

OFFICER'S INFORMATION

IF CITATIONS ISSUED

OTHER VEHICLE AND DRIVER

WITNESSES

INJURIES

POINTS OF IMPACT

ROAD AND WEATHER CONDITIONS

OTHER INFORMATION

YOUR INFORMATION AND SIGNATURE

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