WEYMOUTH POLICE DEPARTMENT ACCIDENT INFORMATION FORM
This Is NOT AN ACCIDENT REPORT, this is a form that allows you to write down the Information You Will
Need If You Are Ever Involved In An Accident (Keep this in your glove
compartment. Hopefully you will never need to use this)
Location
of Accident:
Date:
_____________Time:____________City:________________________________State______
Street and/or route:
________________________________________________________________
The Other Operator’s Information:
Name:
_____________________________________________ License.#_____________________
Address: ___________________________________________ Date Of
Birth:__________________
City:
_______________________________________________State: _____ Area Code: _________
The Other Motor Vehicle’s Information:
Owner’s Name:
________________________________________ License Plate: _______________
Address: _________________________________________________________
State: _________
City: _______________________________________ State:
_______ Make of Vehicle: _________
Insurance
Co.:_____________________________________________________ Style:
_________
Damage to Other
Vehicle:____________________________________________ Color:
_________
_______________________________________________________________
Year: _________
Witness:
Name: ______________________________________________Phone
Number:________________
Address:
________________________________________________________________________
City: ____________________________________________________________
State: _____
Statement:___________________________________________________________________
Injured:
Name: ___________________________________Age: _______
Operator__ Which Vehicle _______
Address:
____________________________________________Passenger__
City:___________________________________ State: _______Pedestrian__
Injury/Situation:_____________________________________________________________________
If you are ever involved in an accident, you must fill out 3 accident reports. (you can get accident reports at any police station, any insurance company or any registry of motor vehicles office). An accident report has to be sent to each. Your insurance company, the police department that has jurisdiction and the Massachusetts Registry of Motor Vehicles. You have 5 working days after the accident to file your report. Please, drive safely.