 | Accident Record Form |
ROBERT J. NEUBERGER ATTORNEY AT LAW 700 JACKSON TOWER 806 SW BROADWAY PORTLAND, OR 97205-3309 (503) 228-1221 rjn@robertneuberger.com http://www.robertneuberger.com |
ACCIDENT RECORD |
DATE: __________________________________ TIME: _______________
LOCATION: ____________________________________________________
YOUR DIRECTION OF TRAVEL: ____________________________________
OTHER CAR'S DIRECTION OF TRAVEL: _____________________________
WEATHER: _________________________ LIGHTING: _________________
TRAFFIC: _________________________ SEATBELTS/CARSEATS: _______
TRAFFIC SIGNS & SIGNALS: _____________________________________
DESCRIBE THE ACCIDENT: _______________________________________
______________________________________________________________
______________________________________________________________
| DESCRIBE PROPERTY DAMAGE |
________________________________________________________
YOUR CAR: _____________________________________________________
_______________________________________________________________
OTHER CAR: ____________________________________________________
_______________________________________________________________
| WITNESS #1: |
____________________________________________________
ADDRESS: ______________________________________________________
PHONE NO. ________________ _________________ ________________
HOME WORK MOBILE
| WITNESS #2 |
____________________________________
ADDRESS: ___________________________________________________
STREETCITYSTATEZIP
PHONE NO. ________________ _________________ ________________
HOME WORK MOBILE
[USE SEPARATE SHEET OF PAPER FOR ADDITIONAL WITNESSES]
| POLICE OFFICER |
_______________________________________
BADGE NO. _______________
AGENCY ________________________________
REPORT? YES NO
| OTHER DRIVER'S NAME |
_________________________________
ADDRESS ______________________________________________
PHONE NO. ________________ _________________ ________________
HOME WORK MOBILE
DRIVER'S LICENSE NO. ________________________
STATE __________________________________
CAR MAKE __________________________ MODEL ____________
COLOR ___________ YEAR _______
LICENSE PLATE NO. ___________ STATE ______________ VIN____________________
| OTHER CAR'S REGISTERED OWNER |
____________________________________
ADDRESS ___________________________________________________
PHONE NO. ________________ _________________ ________________
HOME WORK MOBILE
| INSURANCE COMPANY |
_________________________________________
POLICY NO. ________________________________
EXPIRATION DATE ___________________
AMOUNT OF INSURANCE ________________________________________________
| AGENT'S NAME |
___________________________
| AGENT'S PHONE NO. |
_______________________
_________________________ ADDRESS ________________________________________________________________PHONE NO. ____________________________ CLAIM NO. __________________________________
| ADJUSTER'S NAME |
| OTHER PEOPLE IN YOUR CAR |
__________________________________________________________________________________________
| OTHER PEOPLE IN OTHER CAR |
__________________________________________________________________________________________
| INJURIES |
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________
| NAMES OF YOUR DOCTORS |
__________________________________________________________________________________________
| TOWING COMPANY |
___________________________________________________________
| LOCATION OF YOUR CAR |
__________________________________________________________________________________________
| CHECKLIST |
- SUBMIT DMV ACCIDENT REPORT (WITHIN 72 HOURS IN OREGON)
DATE SUBMITTED ____________________________________________
TO WHOM? ___________________________________________
- NOTIFY YOUR AUTOMOBILE INSURANCE COMPANY.
DATE AND TIME NOTICE GIVEN ________________________________________
NAME OF PERSON TAKING THE NOTICE __________________________________
CLAIM NUMBER ASSIGNED ___________________________________________
(SPECIAL FORMS AND DOCUMENTS MUST BE SUBMITTED QUICKLY WHERE THE OTHER DRIVER IS UNINSURED, HIT AND RAN, OR CANNOT BE IDENTIFIED.) - IF INJURED WHILE ON THE JOB, NOTIFY YOUR EMPLOYER AND SUBMIT AN ACCIDENT REPORT IMMEDIATELY. DATE NOTIFIED ________________________________________________
DATE ACCIDENT REPORT SUBMITTED _______________________________
- TAKE PHOTOGRAPHS OF DAMAGE TO YOUR CAR
DATE TAKEN _____________________________________
LOCATION OF PHOTOGRAPHS AND NEGATIVES ___________________________________
ROBERT J. NEUBERGER
ATTORNEY AT LAW
700 JACKSON TOWER
806 SW BROADWAY
PORTLAND, OR 97205-3309
(503) 228-1221
rjn@robertneuberger.com
http//www.robertneuberger.comPLEASE CONTACT US FOR COMPLIMENTARY COPIES OF THIS BROCHURE, OR IF YOU HAVE ANY QUESTIONS.
Robert J. Neuberger
Attorney at Law
700 Jackson Tower
806 SW Broadway
Portland, Oregon 97205
Phone: 503-228-1221
Toll Free: 1-877-631-5126
Fax: 503-228-2556
Email: rjn@robertneuberger.com
Copyright © 2008 by Robert J. Neuberger. All rights reserved. You may reproduce materials available at this site for your own personal use and for non-commercial distribution. All copies must include this copyright statement.
