WP E-Signature by Approve Me - Sign Documents Using WordPress -

Driver’s Collision Report Form

Driver/Vehicle Information

Name of Driver	Driver's Age	Driver License No.	State

Driver's Address	City	State	Zip	Telephone No.

Name of Nonprofit / Employer	ANI/NIAC Policy Number
GSA Network	#####

Nonprofit/Employer Contact Name	Contact Email Address
Ginna Brelsford, Co-Executive Director	gbrelsford@gsanetwork.org

Nonprofit / Employer Address – Street	City	State	Zip	Telephone No.
1714 Franklin St #100-418	Oakland	California	94612-3409	415.552.4229

Make of Nonprofit’s Vehicle	Body Type	Year	License Plate #	V.I.N. (last four digits)

Damage to Nonprofit’s Vehicle:

Did you take any digital photos?	Dashboard Camera	Transponder/GPS	IMPORTANT: If you answered yes to any of these questions, be sure to preserve any photos, video and/or equipment data.
YesNo	YesNo	YesNo

Collision Information

Date of Collision	Day of Week	Time of Collision	Location - Street or Highway & City

On what street were you driving?	Direction	Speed (approximate)
	North South East West

On what street was other vehicle driving?	Direction	Speed (approximate)
	North South East West

Police Report?	If yes, name of reporting officer	Agency	Citation/Report #
YesNo

Witness Name #1 (first & last)	Telephone No.	Email Address

Witness Name #2 (first & last)	Telephone No.	Email Address

Witness Name #3 (first & last)	Telephone No.	Email Address

Description of Collision (include weather and road conditions):

Passenger(s) in Your Vehicle

Name (first and last)	Telephone No.	Email Address	Age	Injuries?
GSA Network Employee				Yes No

Name (first and last)	Telephone No.	Email Address	Age	Injuries?
				Yes No

Name (first and last)	Telephone No.	Email Address	Age	Injuries?
				Yes No

Name (first and last)	Telephone No.	Email Address	Age	Injuries?
				Yes No

Ambulance called to scene?	Name of doctor or hospital
YesNo

Other Vehicle Involved

Name of Driver	Driver License No.	State

Driver's Address	City	State	Zip	Telephone No.	Email

Name of Vehicle Owner (if different than above)	Telephone No.	Email Address

Name of Insurance Company	Policy #	Telephone No.

Year/Make of Vehicle	Body Type	License Plate No.	State

Damage to Vehicle:

Passenger’s Name (first and last)	Telephone No.	Email Address	Age	Injuries?
				YesNo

Passenger’s Name (first and last)	Telephone No.	Email Address	Age	Injuries?
				Yes No

Other Vehicle Involved (if any)

Name of Driver (first and last)	Driver License No.	State

Address - Street	City/State/Zip	Telephone No.	Email Address

Name of Vehicle Owner (if different than above)	Telephone No.	Email Address

Name of Insurance Company	Policy #	Telephone No.

Year/Make of Vehicle	Body Type	License Plate No.	State

Damage to Vehicle:

Passenger’s Name (first and last)	Telephone No.	Email Address	Age	Injuries?
				Yes No

Passenger’s Name (first and last)	Telephone No.	Email Address	Age	Injuries?
				Yes No

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

October 6, 2020 11:39 am PST

Driver’s Collision Report Form Uploaded by Anna Davis - adavis@gsanetwork.org IP 24.99.105.85