Vehicle Incident Report Form Changes and reports are NOT effective until we are able to confirm them with you directly in person or over the phone.   Who Are You? First Name   Last Name   Email Address   Home Phone   Work Phone Date - - - - - - - - - January February March April May June July August September October November December / - - 01 02 03 04 05 06 07 08 09 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Information About the Incident   Where did the Accident Occur?   What Authorities were Contacted?   List any Violations or Citations Description of Accident & Damage Insured Vehicle Information Year   Make   Model Who was driving the Insured Vehicle? Drivers Name   Relationship to Owner Other Parties Information Describe Damage to Other Parties Property   Other Parties First and Last Name   Other Parties Home Phone   Other Parties Work Phone   Other Parties Address (City, State, Zip)   Other Parties Insurance Company   Other Parties Policy Number   Other Parties Drivers License Number   Other Parties License Plate Number Were there any Injuries? Names, Addresses and Phone Numbers of ALL Injured Parties Also give a brief description of the injuries and the role of the injured part; pedestrian, driver, passenger, etc... Were there any Witnesses? Names, Addresses and Phone Numbers of Witnesses If there is over $1500 damage to either vehicle, a fatality, or a person is transported in an emergency vehicle, you must complete an Oregon Vehicle Accident Report.   Would you like assistance in filing this report?   Yes No   Changes and reports are NOT effective until we are able to confirm them with you directly in person or over the phone.