DA 2041

Rev. 12/98

ACCIDENT REPORT

LOUISIANA STATE DRIVER SAFETY PROGRAM

Submit report to ORM

within 48 hours of accident

Supervisor

to complete

first 4 items

1. Agency Name

 

     

2. Person to Contact

 

     

3. Phone

 

[     ]      -     

4. Loc. Code

 

     

5. State Vehicle Driverís Name

 

     

6. Driverís Social Security No.

 

     -     -     

7. Date of Accident

 

     /     /     

8. Time of Accident

                                        AM

                                PM

9. Exact Location of Accident (Use street markers, mileage markers, etc., to pinpoint location)

 

     

10.

DESCRIBE

HOW ACC.

HAPPENED

 

     

 

     

  11.Seat Belt in Use

        Yes    No

 

     

STATE VEHICLE INFORMATION

 

If other then vehicle damage, fill in as much as possible under ďOther VehicleĒ section substituting property owner information for vehicle driver.

12. State Vehicle Driverís Address (Street No)

     

City

 

     

State

 

     

Zip Code

 

     

13. Home Phone

 

[     ]      -     

14. Work Phone

 

[     ]      -     

15. Driverís License No.

 

     

16. Age

 

     

17. Sex

 

 M  F

18. Vehicleís Ownerís Name and Address

 

                                                                                            

19. Year Vehicle

 

     

20. Make Vehicle

 

     

21. Model Vehicle

 

     

22. Body Type

 

     

23. Vehicle Lic. No. / Equip No. / VIN

 

     

24A. Where can the Vehicle be Seen ?

 

     

24B. Describe Damage

 

     

OTHER VEHICLE INFORMATION

 

If more than one vehicle is involved, submit additional sheet with information on other vehicle(s).

25. Other Vehicle Driverís Name

 

     

26. Driverís Social Security No.

 

     -     -     

27. Driverís License No.

 

     

28. Age

 

     

29. Sex

 

 M  F

30. Other Vehicle Driverís Address (Street No.)

 

     

City

 

     

State

 

     

Zip Code

 

     

31. Home Phone

 

[     ]      -     

32. Work Phone

 

[     ]      -     

33. Vehicle Ownerís Name and Address (Street No.)

 

     

City

 

     

State

 

     

Zip Code

 

     

34. Year Vehicle

     

35. Make Vehicle

 

     

36. Model Vehicle

 

     

37. Body Type

 

     

38. Vehicle I.D. No. or Lic. No.

 

     

39. Where can the vehicle be seen ?

 

     

40. Other Vehicle Insurance Co.

 

     

41. Policy No.

 

     

42. Describe Damage

 

     

43.Estimated Amount

 

$            .     

INJURED

44. Name and Address

 

     

 

 

     

45. Phone

 

[     ]      -     

46.

PED

47.

Ins. Veh.

48.

Other Veh.

49. Police Investigated ?

 

        Yes       No

44. Name and Address

 

     

 

 

     

45. Phone

 

[     ]      -     

46.

PED

47.

Ins. Veh.

48.

Other Veh.

49. Type Report

                   State

 Sheriff    City

44. Name and Address

 

     

 

 

     

45. Phone

 

[     ]      -     

46.

PED

47.

Ins. Veh.

48.

Other Veh.

49. Report No. (Item No.)

 

     

WITNESSES OR PASSENGERS

50. Name and Address

 

     

 

 

     

51.

      Witness

      Passenger

52. Phone

 

[     ]      -     

53.

PED

53.

Ins. Veh.

53.

Other Veh.

53. (Specify)

 

     

50. Name and Address

 

     

 

 

     

51.

      Witness

      Passenger

52. Phone

 

[     ]      -     

53.

PED

53.

Ins. Veh.

53.

Other Veh.

53. (Specify)

 

     

54. State Driverís Signature

 

 

55. Name of Driverís immediate Supervisor and Phone No.

 

     

 

 

[     ]      -