Free Wisconsin Driver Report of Accident - Wisconsin

Wisconsin
.

DRIVER REPORT OF ACCIDENT
DO NOT COMPLETE this Driver Report of Accident if a law enforcement officer completed a Wisconsin Motor Vehicle Accident Report. COMPLETE this Wisconsin Driver Report of Accident if: · There was $1000 or more damage to any one person's property - OR · Anyone was injured - OR · There was $200 or more damage to government property, other than vehicles.
MV4002 12/2005 s.346.70(2) Wis. Stats.
Wisconsin Department of Transportation

Please provide all requested information. Print clearly.
1. 2. 3. You are "Unit 1". An individual involved in the accident must sign the report. Provide all information on the other driver(s)/owner(s) involved. Incomplete reports may be returned requesting missing information. If you need assistance, contact your insurance agent, local law enforcement agency, or the DOT Traffic Accident Section at 608-266-8753. Use the "Narrative" and "Diagram" sections to explain how the accident happened. If more space is needed, use plain paper and attach to this report. This form is available at www.dot.wisconsin.gov/drivers/drivers/traffic/accident.htm.

4. 5. 6.

Retain a copy of this report for your records before mailing. Mail completed report to address shown below.
(Fold report so that address panel shows to outside - tape bottom edge closed and mail - Do not staple).

Important - Please print your return address:

A

Place stamp here Post Office will not deliver without postage

Next page

TRAFFIC ACCIDENT SECTION WISCONSIN DEPT OF TRANSPORTATION PO BOX 7919 MADISON WI 53707-7919

( 5 3 7 0 7 7 9 1 9 2 )

Clear Form

CONTINUE ONLY ...if there was $1000 or more damage to any one person's property, OR ...if anyone was injured, OR ...if there was $200 or more damage to government property, other than vehicles. County of City, Village or Township of Hit and Run Accident? ACCIDENT Month Day ACCIDENT YES DATE Total Units Involved Total Injured LOCATION Name and Number of Street(s) or Highway or Parking Lot

WISCONSIN DRIVER REPORT OF ACCIDENT
(See instructions on reverse side before completing - Please Print). Year Day of Week Time

a.m. p.m.

*

TYPE OF ACCIDENT

(Please

check

one)
1

Hit another motor vehicle in operation
Sex

Hit a parked vehicle
2 3

Hit a deer
4,5

Hit a bicyclist or pedestrian

Other
9

U N I T 1

Driver Full Name (Last, First, MI)

Address

Birth Date

City, State

ZIP Code

Daytime Telephone Number

(
Driver License Number

)
Issuing State

U N Address I T City, State 2

Driver Full Name (Last, First, MI)

Sex

Birth Date

ZIP Code

Daytime Telephone Number

(

)
Issuing State

Driver License Number

Vehicle Legally Parked

Operating a commercial vehicle?

If yes, circle appropriate classification

Vehicle Legally Parked

Operating a commercial vehicle?

If yes, circle appropriate classification

YES

YES

A

B

C

YES

YES

A

B

C

Owner Full Name (Last, First, MI)

Owner Full Name (Last, First, MI)

Address

Address

City, State

ZIP Code

Daytime Telephone Number

City, State

ZIP Code

Daytime Telephone Number

(
License Plate Number Exp Yr Issuing State Vehicle Make Year

)
Color License Plate Number Exp Yr Issuing State

(
Vehicle Make Year

)
Color

Vehicle Identification Number

Vehicle Identification Number

Was a motor vehicle liability insurance policy in effect on the day of the accident?

Policy Holder's Name

Was a motor vehicle liability insurance policy in effect on the day of the accident?

Policy Holder's Name

NO

YES

NO

YES

Exact Name of Insurance Company

Exact Name of Insurance Company

*INJURED
Unit No. Unit No.

Injury Codes: A=Severe, B=Moderate, C=Minor Important - Number of injuries reported must equal number entered in "Total Injured" box above. For additional injuries, provide the information on a separate piece of paper and attach.
Address City, State ZIP Code Sex Birth Date Injury Code

Name (Last, First, MI)

Name (Last, First, MI)

Address

City, State

ZIP Code

Sex

Birth Date

Injury Code

VEHICLE Unit 1 - Important - Circle the numbers closest to the damaged areas. 6 7 8 DAMAGE Damage Estimate
FRONT REAR

Unit 2 - Important
Damage Estimate (If Known)

- Circle the numbers closest to the damaged areas. 6
REAR

7

8
FRONT

(Required)
5

1

5

1

$______________

4

3

2

$______________

4

3

2

PROPERTY DAMAGE

Describe what was damaged. Property damage includes structures, trees, fences, towed items, etc. Do NOT include vehicle damage.

Property Owner Full Name (Last, First, MI)

Address, City, State, ZIP Code

Daytime Telephone Number

( NARRATIVE
Print a brief description of the accident.

)

DIAGRAM

Draw a basic picture of the accident and location.

Indicate North by putting an arrow in the circle.

X
(Signature Required)
Print