DA 2041

Rev. 12/98

ACCIDENT REPORT

LOUISIANA STATE DRIVER SAFETY PROGRAM

Submit report to ORM

within 48 hours of accident

SUPERVISOR

TO COMPLETE

FIRST 4 ITEMS

1. Agency Name

2. Person to Contact

3. Phone

[       ]         -      

4. Loc. Code

5. State Vehicle Driver’s Name

6. Driver’s Personnel No.

7. Date of Accident

      /       /      

8. Time of Accident

AM

      PM

9. Exact Location of Accident (Use street markers, mileage markers, etc., to pinpoint location)

10.

DESCRIBE

HOW ACC.

HAPPENED

11.Seat Belt in Use

        Yes No

STATE VEHICLE INFORMATION

If other then vehicle damage, fill in as much as possible under “Other Vehicle” section substituting property owner information for vehicle driver.

12. State Vehicle Driver’s Address (Street No)

City

State

Zip Code

13. Home Phone

[       ]       -      

14. Work Phone

[       ]         -        

15. Driver’s License No.

16. Age

17. Sex

  M F

18. Vehicle’s Owner’s Name and Address

19. Year Vehicle

20. Make Vehicle

21. Model Vehicle

22. Body Type

23. Vehicle Lic. No. / Equip No. / VIN

24A. Where can the Vehicle be Seen ?

24B. Describe Damage

OTHER VEHICLE INFORMATION

If more than one vehicle is involved, submit additional sheet with information on other vehicle(s).

25. Other Vehicle Driver’s Name

26. Driver’s Social Security No.

      -       -      

27. Driver’s License No.

28. Age

29. Sex

  M F  

30. Other Vehicle Driver’s Address (Street No.)

City

State

Zip Code

31. Home Phone

[       ]         -      

32. Work Phone

[       ]         -        

33. Vehicle Owner’s Name and Address (Street No .)

City

State

Zip Code

34. Year Vehicle

35. Make Vehicle

36. Model Vehicle

37. Body Type

38. Vehicle I.D. No. or Lic. No.

39. Where can the vehicle be seen ?

40. Other Vehicle Insurance Co.

41. Policy No.

42. Describe Damage

43.Estimated Amount

$       .      

INJURED

44. Name and Address

45. Phone

[       ]         -      

46.

PED

47.

Ins. Veh.

48.

Other Veh.

49. Police Investigated ?

        Yes No

44. Name and Address

45. Phone

[       ]         -      

46.

PED

47.

Ins. Veh.

48.

Other Veh.

49. Type Report

State

Sheriff City

44. Name and Address

45. Phone

[       ]         -      

46.

PED

47.

Ins. Veh.

48.

Other Veh.

49. Report No. (Item No.)

WITNESSES OR PASSENGERS

50. Name and Address

51.

      Witness

      Passenger

52. Phone

[       ]         -      

53.

PED

53.

Ins. Veh.

53.

Other Veh.

53. (Specify)

50. Name and Address

51.

Witness

Passenger

52. Phone

[       ]         -      

53.

PED

53.

Ins. Veh.

53.

Other Veh.

53. (Specify)

54. State Driver’s Signature

55. Name of Driver’s immediate Supervisor and Phone No.

[       ]         -