THE ACCIDENT / INCIDENT			INJURED PERSONS	
				
Date of Accident:		Time:		 AM  PM			Were there any injuries reported?	 Yes  No	
Location of Accident:				If yes, you MUST call Risk Management Division immediately at 1-800-525-1252.	
Town/City:					
Nearest Landmark:					
Weather Conditions:				Name of injured person:		
Road Conditions:				Address:		
Police Department:				Location in accident:		
Investigating Officer:				Description of injury:		
STATE VEHICLE (#1)			Age:		Gender:		Phone#		
					
Driver:				Name of injured person:		
Home Address:				Address:		
City:		State:		Zip:				Location in accident:		
Phone: Home#		Work#				Description of injury:		
Date of Birth:		Driver’s License#				Age:		Gender:		Phone#		
Dept:		Bureau/Division:					
Direct Supervisor:				DESCRIPTION OF ACCIDENT/INCIDENT	
Vehicle Year, Make, Model:					
Plate#:		Mileage:					
Description of Damage:					
Estimate of Damage:	$				
Is this an authorized emergency vehicle?	 Yes  No				
Is this a Central Fleet Management vehicle?	 Yes  No				
(IF YES AND THERE IS ANY DAMAGE TO CFM VEHICLE, CONTACT CENTRAL FLEET AS SOON AS POSSIBLE AT 
1-800-300-7013 WITHIN MAINE OR 207-287-7012 OTHERWISE)				

OTHER VEHICLE (#2)				
			Use additional space on back to complete description or draw a diagram.	
Driver:				PASSENGERS OR WITNESSES	
Street Address:					
City:		State:		Zip:				Name:		
Phone: Home#		Work#				Address:		
Driver’s Date of Birth:		License#:				Location in accident:		
Owner:						
Street Address:				Name:		
City:		State:		Zip:				Address:		
Phone: Home#		Work#				Location in accident:		
Vehicle Year, Make, Model:					
Plate#:				I HAVE READ AND COMPLETED THIS ACCIDENT / INCIDENT REPORT.  THIS STATEMENT IS CORRECT TO THE BEST OF MY KNOWLEDGE.	
Description of Damage:					
Insurance Agent or Company:					
Address:					
Phone#		Policy#					
				r				
Were other vehicles/drivers involved?	 Yes  No							
Any other property damage?	 Yes  No			Driver’s Signature (REQUIRED)		Date	
If yes to either of these questions, please provide information on the back or a separate form if necessary.				
			FOR RISK MANAGEMENT DIVISION USE ONLY
File#