Police Information
Accident Scene Diagram
Were Police or Emergency Responders Present?
Yes
No
Official #1 Name
Accident Scene Checklist
Badge/Contact Info
Stop. Turn on emergency flashers. Only
move your vehicle if directed to do so by an
officer.
Agency
Official #2 Name
Badge/Contact Info
Shut down your vehicle. Remain calm.
Only exit when it is safe to do so. Keep
yourself protected.
Agency
Arrests?
Yes
No
Quickly survey the area and check for
imminent hazards (other traffic, fuel spill,
fire, electrical, etc)
Names:
Secure the scene; set out reflective triangles,
flares or other emergency equipment.
Narrative Describe Accident
Check for injuries; never move injured
parties; only offer assistance (blanket,
water, pillow, etc)
Notify police (4-1-1 on cell phone or
Nextel). If these are unavailable, ask
witness or passerby to call for you.
Notify your company and any service
providers (leasing company, hazmat or spill
containment teams, etc)
Give witnesses a card to fill out. If they
refuse, document their actions and ID (car,
license #, description, etc)
Thorn Valley Enterprises
8498 W. Fall Creek Drive
Pendleton, IN 46064
Phone (888) 485-0767
Fax (485)-5386
www.thornvalleyent.net
If other party admits fault and is willing to
do so, have them fill out an Exoneration
Card.
Document the scene. This is critical material facts could change once scene is
cleaned up. Include all details.
Photograph scene (not victims). Start from
300 from scene & every 50 approaching it.
Use up all film.
Accident Information
Other Party #1 Information
Your Driving Information
Date
Company Name
Direction of travel
Time
Driver Name
Estimated speed
Location
Address
Headlights on?
City
ST
Lane of travel
Drivers Lic#/ST
Your Information
Road and Weather Information
Expiration Date
Company
Vehicle#/Desc
Name
Year
Address
Color
Make
Towed?
Yes
No
Lic#/ST
TL Yr
Drivers License ST
Company Name
Expiration Date
Driver Name
Your Vehicle Information
Make
Color
Towed?
Yes
Lic#/ST
Vehicle#/Desc
TL Lic#/ST
Year
Your Cargo Information
Cargo Damaged?
Yes
No
Cargo description
Extent
Make
Color
Towed?
Lic#/ST
Trailer# /Desc
TL Yr
TL Make
Visibility
Est. Cargo value $
Fuel Spill?
Phone
Expiration Date
TL Make
Yes
No
Daylight
Dusk
Other
No
Traffic controls?
Yes
No
If yes, type
Level
Debris
Oily
Snow
Wet
4W Stop
2W Stop
R Turn on Red
Yield
Lane closure
Flashing Yellow
Other
Drivers Lic#/ST
Trailer# /Type
TL Yr
No
Yes
Curve
Grade
Rain
Mud
Fog
Traffic Controls
Address
Vehicle#/Desc
Year
TL Make
Other Party #2 Information
DL#
Divided roadway?
Straight
Hilly
Pothole
Ice
Dry
Other
Trailer# /Desc
Phone
No
# Lanes (each way)
Phone
Landmarks
Yes
Dark
Street light
Yes
No
4W Lights
2W Lights
RR Xing
Merge
Construction
Flashing Red
Traffic Conditioins
None
Contested
Light
Stop & Go
Rush Hour
Other
Heavy
Moderate
Normal
Merging
