THE ACCIDENT / INCIDENT
Date of Accident:__________ Time:________   AM   PM
Location of Accident:__________________________________
Town/City:__________________________________________
Nearest Landmark:____________________________________
Weather Conditions:___________________________________
Road Conditions:_____________________________________
Police Dept:_________________________________________
Investigating Officer:__________________________________

STATE VEHICLE (#1)
Driver:______________________________________________
Home Address:_______________________________________
Town:______________________ State:______ Zip:__________
Date of Birth:____________ Driver’s License #:_____________
Dept:________________ Bureau/Division:_________________
Direct Supervisor:_____________________________________
Vehicle Year, Mark, 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 THERE IS DAMAGE TO CFM VEHICLE, CONTACT THEM AS SOON AS POSSIBLE AT 1-800-300-7013 WITHIN MAINE OR 207-287-5521 

OTHER VEHICLE (#2)
Driver:_____________________________________________
Street Address:_______________________________________
Town:______________________ State:______ Zip:_________
Phone #_____________ Email:__________________________
Driver’s Date of Birth:____________ License #_____________
Owner:_____________________________________________
Street Address:_______________________________________
Town:______________________ State:______ Zip:_________
Phone #_____________ Email:__________________________
Vehicle Year, Make, Model:_____________________________
Plate #______________________________________________
Description of Damage:________________________________
Insurance Agent or Company:___________________________
Address:____________________________________________
Phone #__________________ Policy #____________________
Were other vehicles/drivers involved?   Yes   No
Any other property damage?                  Yes   No

If yes, please provide information on the back or a separate form.
INJURED PERSONS
Were there any injuries reported?  Yes   No
If yes, you MUST call Risk Management Division immediately at 1-800-525-1252.
Name of injured person:________________________________
Address:____________________________________________
Location in Accident:__________________________________
Description of injury:__________________________________
Age:_______ Gender:_______ Phone #____________________
Name of injured person:________________________________
Address:____________________________________________
Location in Accident:__________________________________
Description of injury:__________________________________
Age:_______ Gender:_______ Phone #____________________
DESCRIPTION OF ACCIDENT / INCIDENT
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Use additional space on back to complete description or draw a diagram. 
Photos are helpful, even if there is no damage. 
PASSENGERS OR WITNESSES
Name:______________________________________________
Address:____________________________________________
Location in accident:___________________________________
Name:______________________________________________
Address:____________________________________________
Location in accident:___________________________________
I HAVE READ AND COMPLETED THIS ACCIDENT / INCIDENT REPORT. THIS STATEMENT IS CORRECT TO THE BEST OF MY KNOWLEDGE.
X_____________________________________   ___________
    Driver’s Signature (REQUIRED)              Date