FORM DATE OF ACCIDENT VEHICLE NUMBER
STATE OF WASHINGTON
S.F. 137
MP EF 3/02
VEHICLE ACCIDENT REPORT
BUDGET NUMBER
INSTRUCTIONS: This report must be mailed within two working days to the following 3 offices:
1 UNIVERSITY POLICE (original) 2 MOTOR POOL OPERATIONS (copy) 3 UW RISK MANAGEMENT (copy)
1117 NE Boat Street Box 355200 4549 25th Ave NE Box 354270 22 Gerberding Hall Box 351276
Seattle, WA 98105 Seattle, WA 98105 Seattle, WA 98195
NAME AGE UW DEPARTMENT POSITION
DRIVER
BUSINESS ADDRESS ZIP BUSINESS PHONE WAS VEHICLE BEING USED ON OFFICIAL YES
STATE BUSINESS?
NO
STATE EMPLOYEE
OPERATOR’S LICENSE NO. LICENSE RESTRICTION? IF YES, INDICATE HAVE YOU HAD A PREVIOUS ACCIDENT YES
YES WHILE DRIVING ON STATE BUSINESS?
NO NO
LICENSE NO. YEAR MAKE BODY TYPE WHERE LOCATED NO. OF PASSENGERS EST. REPAIR COST
VEHICLE NO. 1
OWNING AGENCY DESCRIBE DAMAGE FULLY (Parts, type, and extent of damage)
IF PRIVATELY OWNED, NAME AND ADDRESS OF OWNER (if State Owned, Equipment No. Only) INSURER
OWNER CAR NO. 2 PHONE OWNER CAR NO. 3 PHONE
ADDRESS CITY ZIP ADDRESS CITY ZIP
DRIVER AGE PHONE DRIVER AGE PHONE
OTHER VEHICLES
ADDRESS CITY ZIP ADDRESS CITY ZIP
DRIVER’S LICENSE NO. VEHICLE LICENSE NO. DRIVER’S LICENSE NO. VEHICLE LICENSE NO.
VEHICLE MAKE YEAR BODY TYPE VEHICLE MAKE YEAR BODY TYPE
NAME OF PASSENGERS NAME OF PASSENGERS
REPAIR COST DESCRIBE DAMAGE REPAIR COST DESCRIBE DAMAGE
INSURANCE COMPANY POLICY NO. INSURANCE COMPANY POLICY NO.
PROPERTY
WHAT WAS DAMAGED? REPAIR COST
OTHER
NAME AND ADDRESS OF OWNER ZIP PHONE
NAME AND ADDRESS EXTENT OF INJURY AGE VEH.1 VEH.2 VEH.3 PED.
INJURED PARTIES
NAME ADDRESS ZIP PHONE
OH R WITNESSES
RPTS.
POLICE INVESTIGATE? WHICH DIVISION (SHERIFF, CITATION ISSUED? YES NO HAVE YOU FILED FINANCIAL YES
TE
YES W.S.P., CITY?) RESPONSIBILITY FORM WSP 161 AS
NO ISSUED TO YOU VEH.2 VEH.3 NO
REQUIRED BY LAW?
COMPLETE ALL DETAILS
DATE OF ACCIDENT TIME LOCATION (STREET) OR NEAR INTERSECTION OF
AM
MO DAY YEAR
PM
CITY AND STATE TYPE OF ACCIDENT FRONT TO REAR HEAD-ON PARKED CAR PEDESTRIAN
BROADSIDE SIDESWIPE BIKE-CAR HIT OBJECT
INFORMATION REGARDING # 1 YOUR VEHICLE # 2 OTHER PARTY (NAME) # 3 OTHER PARTY (NAME)
ACCIDENT
1. If pedestrian, where was he/she
(crosswalk, etc.)?
2. Road conditions (dry, glare, icy,
rain, snow, etc.)?
(Gravel, blacktop, etc.)
3. At what distance was danger first
noticed?
4. Speeds at time danger was first
noticed?
5. Speeds at time of accident?
6. What warning signals were given?
7. Obstruction to vision (weather and
other)?
8. Lights on? Wipers on? Windows
fogged?
9. Had any party been drinking?
Who?
DESCRIBE IN DETAIL WHAT HAPPENED (USE ADDITIONAL PAPER IF NECESSARY)
STRAIGHT ROAD HILLCREST ONE LANE MARK DAMAGED AREA
CURVE - R or L UPHILL ONE AND ONE-HALF LANE
RIGHT
LEVEL DOWNHILL TWO LANE OR FOUR LANE
Show on diagram position of each car, VEH.
vehicle or injured person, indicating by 1
arrow direction of each.
LEFT
SIDEWALK
STREET
RIGHT
CENTER
SIDEWALK
VEH.
2
IMPORTANT: If street or view was
obstructed in any way, indicate where and
how; also indicate any street car or tracks
LEFT
and traffic signal or signs.
Indicate points of compass
N. E. S. W.
SIGNATURE (DRIVER) DATE SIGNATURE (SUPERVISOR) DATE
FORM S.F. 137 (MP EF 3/02)