Operator-Driver Auto Accident Information

This operator-driver auto accident form can help in the post-accident data gathering process. It is beneficial to have accurate and detailed information so that the proper loss control measures can be implemented to prevent future occurrences.

Name ____________________________________________________________
(Last name) (First name) (M.I.)

Age_____________________

1. Type of accident:

Intersection _____

Rear-end _____

Backing _____

Other description: ________________________________________________________

2. What was the estimated speed 150 feet prior to the intersection? ___

3. What was the estimated speed prior to the impact? ____

4. Did you come to a complete stop before entering the intersection?
Yes __ No __

Explain: _________________

5. If you did not come to complete stop prior to entering the intersection, what was your estimated speed entering the intersection? ______

6. Did you make eye contact with the drivers of the other vehicles who were yielding the right of way, before entering the intersection? Yes __ No __ explain: ________________________

7. Did you stop at each lane that did not have a vehicle stopped in the lane before you crossed the lane? Yes __ no __ explain: _________________

8. Were you upset prior to the accident? Yes___ No _____
explain: _________________

9. Did you experience any brake fade or failure prior to the impact?
Yes __ No __
Explain: _________________

10. Did you have any mechanical problems with the vehicle prior to the accident? Yes __ No __
Explain: ____________________________________________________

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