| Date: ___________________________________________
Time: ___________________________________________
City: ____________________________________________
Street: __________________________________________
Condition of Road: _________________________________
Weather: _________________________________________
Direction of your car: ________________________________
Speed of your car: __________________________________
Direction of other car: ________________________________
Speed of other car: __________________________________
Did the police take a report?: ___________________________
Responding police department: _________________________
Case / Report Number: ________________________________
Please give a brief description of how the accident occurred:
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