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