SR 13 Form Georgia Fillable Template

2. Give exact time of accident date day and hour. 3. Under Location of Accident show sufficient information to locate exact scene of the accident. PERSONAL REPORT OF ACCIDENT This form should be completed when a traffic accident occurs and a law enforcement officer is not called to make a report. ROAD ACCIDENT OCURRED ON Give name of street or highway number U.S. or State. If no highway number identify by name. L O C A T I N V E H S Space for any third vehicle on reverse side. Total involved Date of Accident Place Where Accident Occurred Day of Week HourA. M. P. M. Weather Clear Raining Fog Etc. DO NOT WRITE IN THIS SPACE City Town County Or Township If accident was outside city miles limits indicate distance from limits of south-north nearest town. Use two disof tances and two directions center of east-west if necessary. This report is for your personal use and should not be mailed to the Department of Driver Services as it will be destroyed upon receipt. Time INSTRUCTIONS 1. Answer all questions to the best of your knowledge. If unable to answer any questions mark not known. 4. Print or type all names and addresses. 5. Sign the report in the space provided on the reverse side. 6. Report must be complete as to exact names birth dates and drivers license numbers. 7. Use a second report form or a sheet of plain paper of the same size to report additional vehicles injured persons or witnesses or any other information for which there is insufficient space. At its intersection with Check and OR complete one Not at intersection Name of intersecting street or highway number of show nearest intersecting street or highway house number bridge driveway or other identifying landmark. YOUR VEHICLE NUMBER 1 Approximate cost Year Make Type sedan truck taxi bus etc* Year State Number Driver Full Name Street City and State Driver s Occupation License Birth DateAgeSex Carpenter Sales Clerk Etc* State Number Mo. Da Yr OwnerOwner s Birth Date Mo Parts of Owner s Vehicle DamagedDriveable Yes No Driver License Is this vehicle covered by Yes IF YES TO EITHER SHOW automobile liability insurance No INSURANCE COMPANY Show name of insurance company not name of insurance agency. If vehicle not covered did driver Yes have liability policy applicable No Show Policy Number Here Address OTHER VEHICLE NUMBER 2 DAMAGE TO PROPERTY OTHER THAN VEHICLE cost to repair NAME OBJECT AND STATE NATURE OF DAMAGE NAME AND ADDRESS OF OWNER OF DAMAGED PROPERTY 3rd J U R D Vehicle No* 3 If third vehicle Involved In Vehicle Passenger Pedestrian Injured Age Sex Race taken to Specify other Nature and Attending Did injured die extent of injuries Doctor taken to Injured Did injured die extent of injuires Light Conditions Daylight Dawn or Dusk Darkness What Pedestrian Was Doing Pedestrian was going N S E W Crossing or entering at intersection Across or intoFromTo Street name highway no. Walking in roadway-with traffic Pushing or working on vehicle Other in roadway Getting on or off vehicle Specify other Standing in roadway Not in roadway Playing in roadway What Drivers Intended To Do Check one for each driver Go straight ahead Overtake and pass Make right turn Make Left Turn Make U Turn Start in Traffic Start from parked position Back Remain stopped in traffic lane Remain Parked Get out of parked or stopped vehicle Witnesses approximate DESCRIBE WHAT HAPPENED Refer to vehicles by number.