Commissioner Darin R. Seeley
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Craig Ambach, Director
Risk Management Contact Information:
1429 East Sioux Avenue
Pierre, SD 57501
ph 605-773-5879
fax 605-773-5880
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State Vehicle Accident Report
< Print Form to Complete by Hand
Accident Information
Type of Accident:
(Check all that apply)
Fatality
Employee Injury
Private Citizen Injury
Damaged Private Property
Damaged State Property
Other
Date of Accident:
* Required
REQUIRED
Time of Accident:
am
pm
* Required
REQUIRED
Location of Accident:
(include mile marker # and closest town if applicable)
* Required
REQUIRED
State Employee / Vehicle
Employee Name:
* Required
REQUIRED
DOB:
(MM/DD/YYYY)
* Required
REQUIRED
(mm/dd/yyyy)
Invalid Date
Title:
* Required
REQUIRED
Employment Status:
Temporary
Permanent
Department:
* Required
REQUIRED
Agency/Division:
* Required
REQUIRED
Work Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Home Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Drivers License Number:
* Required
REQUIRED
Where Can Vehicle Be Seen:
* Required
REQUIRED
Date Reported to Supervisor:
* Required
REQUIRED
Vehicle Serial Number:
* Required
REQUIRED
Vehicle Make:
* Required
REQUIRED
Vehicle Year:
* Required
REQUIRED
Vehicle License Plate Number:
* Required
REQUIRED
Describe Damages/Injuries - Repair Estimate:
* Required
REQUIRED
Other Parties Vehicle / Property
Name:
* Required
REQUIRED
DOB:
(MM/DD/YYYY)
* Required
REQUIRED
(mm/dd/yyyy)
Invalid Date
Employer:
Role:
Witness
Driver
Private Citizen
Address:
* Required
REQUIRED
Home Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Work Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Drivers License Number:
Owner of Vehicle/Property:
(include address and phone)
* Required
REQUIRED
Company Insuring Vehicle/Property:
(include address and phone)
* Required
REQUIRED
License Plate Number & State:
Vehicle Make:
Vehicle Year:
Where Can Vehicle Be Seen:
Witness:
Describe Damage/Injury - Repair Estimate:
* Required
REQUIRED
List Injured Parties:
Accident Description
Describe in detail:
* Required
REQUIRED
Include Pictures Here:
Legal
Was Law Enforcement Contacted?
Yes
No
Name of Law Enforcement Agency:
Citation Issued?
Yes
No
Type of Citation:
Citation Issued To:
State Employee
Private Citizen
Citation Issued By:
Signature
Signature:
(type name in signature box)
* Required
REQUIRED
Date:
* Required
REQUIRED