VEHICLE ACCIDENT REPORT Today’s Date
To be completed by the state driver within 24 hours (replaces DRM-01 Form)
Type of Incident Fatality Injury Private party injury or property damaged Other
Driver Information
Driver Name Job Title Driver License Number/ State
Date of Hire Permanent Address Home Phone
Temporary
Has the driver had Defensive Driving YES City State Zip Work Phone
training within the past 4 years? NO
State Vehicle Information
Vehicle #, if applicable Year Make Model Vehicle Identification Number (VIN)
License Plate Number Mileage
Accident during business use? State Fleet Vehicle? 0 0 0 0 0
Yes No Yes No 0
Location of Vehicle/ Tow Company
0 0
0-None
Describe Damage to vehicle (Attach Photos) 0 0 0
0 0 0 0 0 0
Accident Information
Date of Accident Time Location of Accident (Street, Highway or intersection) Mile Post
City State CDOT Use Only
Transported to Hospital Yes No Doctor Hospital/Clinic City Phone
By Ambulance
Other Vehicle Information (use additional sheet if necessary)
Year Make Model License Plate Number Drivers License Number
Owner Name Phone Address City State Zip
Driver Name (if other than owner) DOB Phone Address City State Zip
Insurance Carrier Policy Number Agent Name / Phone Number
Area of Damage to Vehicle Vehicle Location
Conditions and Accident Description (use additional sheet if necessary)
Weather Conditions (Circle those that apply) Road Conditions (Circle those that apply) Air Bag Deployed?
Rainy Clear Fog Snow/Ice Wind Paved Dirt/Gravel Dry Wet Slippery Yes No
Traffic Controls (Signs, Signals, Lights) Posted Speed Limit How fast were you traveling? Seat Belts Worn
Yes No
Witnesses (If none, write N/A)
Name Address City State Zip Phone
Name Address City State Zip Phone
Passengers (If none, write N/A) circle one
Name Address City State Zip Phone State veh.
Other veh.
Name Address City State Zip Phone State veh.
Other veh.
OVER
Description of the Accident
Draw picture only if accident was in parking lot or
other off-road area.
Injuries to state employee and/or other party (use additional sheet if necessary)
Name State employee? Address City State Zip
Phone Estimated extent of Injuries
Name State employee? Address City State Zip
Phone Estimated extent of Injuries
Police Information
Were Police Called? Police Department Name Badge Number Phone Number
Yes No
Police Report Number Citation / Ticket Issued / Reason Who was cited (State driver, Other party)?
State Driver Signature Phone Date
Supervisor Signature Title Phone Cost Center Date
Instructions:
Check to make sure no one is injured. If so, request medical assistance immediately
If your vehicle is drivable, state law requires you to move it off of the traveled portion of the roadway as soon as practical. If not drivable, turn
on hazard lights, and if available, set up flares or reflector triangles to warn traffic. Stay in your vehicle.
Call the police immediately, even if it appears minor. If police will not respond, due to an “accident alert” situation or do not come, fill out an
accident report at the city courthouse/ police station in the city in which the accident occurred.
Ask the police officer, if completed, where and when you can get a copy of their report.
Do not argue with the others involved, admit fault or discuss the accident with anyone except the police.
Give the other driver your vehicle insurance policy number (should be kept with vehicle registration information.)
Gather as much information about the accident as possible. Photograph the scene and vehicle damage if possible.
