Use this form in case of an auto accident.  The form should be filled out at the scene or shortly after leaving the scene.

The Accident:

Date of accident______________________
Time_________________
Location of accident __________________
Type of road (grade, curve, etc.) ______________________
Speed of your car just before accident __________________
Speed of other car just before accident __________________
Direction of your car ____________________
Direction of other car ____________________
Were you turning? ______________________
Was other driver turning? _________________
Did the other driver signal properly (with arm, horn, lights, etc.)? ___________________
If at night, were other vehicle’s lights on? _______
How far away from you was the other car when you first saw it? ____________________
Other pertinent facts:
____________________________________
____________________________________

The Other Driver and His or Her Car:

Name:___________________________________
Street Address:_____________________________
City__________________________ State __________ Zip ______
Vehicle registration/year/license number________________________
Make/model of car_________________________ Year___________
Driver appear to have been drinking?__________________________
Any statement made by other driver as to cause of accident:
________________________________________
________________________________________

Passengers in Other Car:

Name:_________________________________________
Address:________________________________________
Name:__________________________________________
Address:________________________________________

All Possible Witnesses to Any Fact:

Name:___________________________________________
Address:__________________________________________
Name:____________________________________________
Address:___________________________________________

Conditions Noted Immediately after the Accident:

Position of your car after accident ____________________________
Position of other car after accident____________________________
Location of any tire marks, blood, broken glass, dirt, etc. on road or side of road ____________________
Location of point of impact in relation to center of road or some physical object ___________________
Did your car skid? _______________
If so, how many feet?___________________________
Did other car skid? _______If so, how many feet?______________
Road conditions_____________________
Traffic conditions____________________
Weather conditions___________________
Traffic controls (traffic lights, stop signs, etc.) _________________
Place of impact on other car _____________________________
Name/address of wrecker that removed other car _____________
Other conditions that affected accident:
__________________________
__________________________

Information Produced By the South Carolina Bar Association