The time of the accident

     Date time

Location of the accident

Road (street) near

The witness or witnesses (name, telephone, etc.):

Vehicle armour (c)

The accident situation

Auto B (d)

The parties involved in the accident

Full name............................... .

ID (passport):

....................................... .

Address:.............................. .

....................................... .

Telephone............................... .

Driver's license file no.:.................. .

The license issuing organs:........................ .

Quasi driving type:........................ .

Valid driving license:.................. .

Please tick out the related grid

The parties involved in the accident

Full name............................... .

ID (passport):

....................................... .

Address:.............................. .

....................................... .

Telephone............................... .

Driver's license file no.:.................. .

The license issuing organs:........................ .

Quasi driving type:........................ .

Valid driving license:.................. .

A (c)

□1

□2

□3

□4

□5

□6

□7

□8

□9

□10

□11

□12

□13

□14

□15

□16

The same lane before the vehicle rear end collision

Reversing or slipping and his car

Collision

Start or open the door

To enter or exit the residential area,

The parking lot or unit

The same to different lane changing

Turn left

Turn right

Straight line

Reverse driving

Running a one-way street

Not according to the guide arrow running

Contravened the mark

Or violate the signal lamp

No signal control intersection is not let

The right side of the road leading to the car

Parking on the driveway

The warning lamp

The intersection is not followed by

Other

B (d)

1 -

2 -

3 -

4 -

5 -

6 -

7 -

8 -

9 -

10 -

11 -

12 -

13 -

14 -

15 -

16 -

The accident vehicle

The owner:.............................. .

The license plate number:........................ .

Label type:........................ .

The engine number:........................ .

The frame number:........................... .

Driving license is valid:.................. .

The accident vehicle

The owner:.............................. .

The license plate number:........................ .

Label type:........................ .

The engine number:........................ .

The frame number:........................... .

Driving license is valid:.................. .

The insurance company

Name............................... .

Cross strong insurance policy number:

....................................... ...

The insured:........................ .

The insurance period from year month day year to year month day time

Commercial three party risk with no □ □

CDW has no □ □

The insurance company

Name............................... .

Cross strong insurance policy number:

....................................... .

The insured:........................ .

The insurance period from year month day year to year month day time

Commercial three party risk with no □ □

CDW has no □ □

Please mark the vehicle collision with the arrow site (available mobile phone camera fixed evidence conditional)

A car (by car):

B cars (Ding Che):

A (c) Party B (d) party signature signature