VEHICLE ACCIDENT REPORT
7225 Parkway Drive
Hanover, Maryland 21076 	1+800-673-8231
TEL: 1+443-561-1700
FAX: 1+443-561-1739
URL: www.lgit.org	
MEMBER CONTACT	DEPARTMENT CONTACT	
NAME AND ADDRESS
     	BUSINESS PHONE
     	NAME AND ADDRESS
     	BUSINESS PHONE
     	
	WHEN TO CONTACT
     		WHEN TO CONTACT
     	
LOSS INFORMATION	
     	CLAIM	DATE OF ACCIDENT
     	TIME OF ACCIDENT
     	     	AM	PREVIOUSLY REPORTED?	
     	INCIDENT			     	PM	YES	     	NO	     	
LOCATION OF ACCIDENT (nearest intersection, city, zip)
     	AUTHORITY CONTACTED:	     	VIOLATIONS/CITATIONS	
			     	     	MEM DRV	
				     	OTH DRV	
	REPORT#: 	     	CAUSE OF ACCIDENT
     	
DESCRIPTION OF ACCIDENT
     	WAS AMBULANCE NECESSARY?	
	YES
     	NO
     	
MEMBER DEPARTMENT VEHICLE	
UNIT#
     	YEAR
     	MAKE: 	     	BODY TYPE: 	     	PLATE NUMBER
     	
		MODEL: 	     	VIN: 	     		
OWNER'S NAME & 
ADDRESS:		BUSINESS PHONE
     	
     	(Check if same as Member)			
DRIVER'S NAME
     	SHERIFF DRIVER'S DUTIES AT TIME OF ACCIDENT
     	
DESCRIBE
DAMAGE:	     	WHERE CAN VEHICLE BE SEEN?
     	WHEN CAN VEHICLE BE SEEN?	
			     	
NON-DEPARTMENT VEHICLE/PROPERTY DAMAGE	VEHICLE?	YES	     	NO	     		
DESCRIBE PROPERTY:
(If auto, year, make, model, vin#, plate#)	     	INSURANCE CO/AGENCY NAME:	     	
		POLICY NUMBER	BUSINESS PHONE	
		     	     	
OWNER'S NAME
AND ADDRESS:	     	RESIDENCE PHONE	
		     	
		BUSINESS PHONE	
		     	
OTHER DRIVER'S 
NAME & ADDRESS:	     	RESIDENCE PHONE	
		     	
     	(Check if same as owner)		BUSINESS PHONE	
			     	
DESCRIBE DAMAGE:	     	
INJURED:  IF MORE THAN ONE INJURED PERSON, FILL OUT AND ATTACH ADDITIONAL ACCIDENT REPORT(S)	
INJURED'S NAME & ADDRESS:	     	PHONE
     	     	PED	SOC SEC#
     	DOB
     	
			     	MEM VEH			
			     	OTH VEH			
ATTENDING
PHYSICIAN NAME &
ADDRESS:	     	PART OF BODY 
     	TRANSPORTED BY AMBULANCE?	
			YES
     	NO
     	
CLAIMANT 
ATTORNEY NAME &
ADDRESS:	     	BUSINESS PHONE
     	
WITNESSES OR PASSENGERS	
WITNESS 1 NAME &
ADDRESS:	      	PHONE
     	     	PED	OTHER (Specify)
     	
			     	MEM VEH		
			     	OTH VEH		
WITNESS 2 NAME &
ADDRESS:	     	PHONE
     	     	PED	OTHER (Specify)
     	
			     	MEM VEH		
			     	OTH VEH		
IMPORTANT: REPORTS SUBMITTED IN HARD COPY MUST BE SIGNED BY MEMBER CONTACT	
REPORT DATE
     	MEMBER CONTACT SIGNATURE
     	INTERNAL REFERENCE NUMBER