Wisconsin Department of Administration Bureau of State Risk Management

DOA-6496 (R08/2000) Vehicle Accident/Incident Report

Instructions: In case of an accident involving a state-owned vehicle, the driver of the vehicle must:
1. Report the accident promptly to a local law enforcement agency and obtain a copy of the officer’s report.
2. Contact your supervisor and fleet manager as soon as practical to report the accident.
3. Within 24 hours of the accident, submit this completed & signed form to your supervisor.
4. Submit this completed form, signed by your supervisor, to the appropriate Fleet Office within 48 hours.
5. If the police do not respond or complete the accident report and the accident has caused bodily injury, vehicle property damage is
$1,000 or more and/or government-owned property damage is $200 or more the driver must submit a completed MV-4002 Driver’s
Report of Accident to the Department of Transportation within ten days. Forward a copy to the fleet office.
Agency/Department Name Division/Institution/Campus Agency Number

Agency/Dept. Supervisor’s Name Phone Number ( )

Location Street Address City ZIP + 4

Street/Highway Accident Date (mm/dd/ccyy)

Location of the
Accident City County State Accident Time AM
PM
State Vehicle Owner Agency/Dept. Name Reason for Vehicle Use
State
Year Make/Model Body Type Mileage Color
Vehicle
Information Fleet Number Vehicle Identification Number License Plate Number

Describe Parts Damaged Circle numbered areas of vehicle damage.

6 7 8
Assigned

Front
Rear
Pool/ 5 1
Functional
4 3 2
Driver Name Driver Injured Home Phone ( ) Work Phone ( )
Information Wearing Seat Belt
Email Address Date of Birth Driver’s License Number
on
Work Address City State ZIP + 4
Driver
of Home Address City State ZIP + 4

State Were There Passengers in This Vehicle? Yes No Injuries Wearing Seat Belt
If Yes, List Names: ______________________________________________ Yes No Yes No
Vehicle
______________________________________________ Yes No Yes No
(Please indicate what type of Describe Parts Damaged If automobile, circle numbered areas of
property was damaged.) vehicle damage.
6 7 8
automobile
fence
Front
Rear

building 5 1
guard rail
other 4 3 2
Property Owner (if different from driver) Home Phone ( ) Work Phone ( )
Other
Home Address City State ZIP + 4
Party(s)
Year Make/Model Body Type License Plate Number
Involved
(add additional Vehicle Identification Number Insurance Company Phone ( )
sheets if more
Agent Name Address
than one other
party involved) Driver Name Home Phone ( ) Work Phone ( )
Driver Injured
Wearing Seatbelt
Home Address City State ZIP + 4

Driver’s License Number

Were there passengers in this vehicle? Yes No Injuries Wearing Seat Belt
If Yes, List Names: ______________________________________________ Yes No Yes No
______________________________________________ Yes No Yes No
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Was the accident investigated by a law Were photographs taken at the scene? By whom?
enforcement agency?
Yes No Yes No
Name of the Investigating Officer Law Enforcement Agency Name Case Number

Were citations issued? To whom?

Yes No
Road Conditions Did the state vehicle have lights on? Did the other vehicle have lights on?
(if other vehicle involved)
Wet Dry Icy Yes No
Yes No
Bright Dim
Other Bright Dim
At what speed were you (state vehicle) traveling? At what speed was the other vehicle traveling? Posted Speed Limit

What traffic controls were in effect? For whom? Who had the right of way?

What signals were given by you? What signals were given by the other driver?

What did you do to avoid the accident? What did the other driver do to avoid the accident?

Name of Witness
Witness
Home Address Phone Number ( )
Information
City State ZIP + 4

Driver Description of the Accident/Incident Attached sheets include additional description, witness and passenger information.

Please complete this diagram. Indicate names of streets, direction, position of vehicles and point of contact. Use a solid line to show
path before the accident and a dotted line to show path after the accident.

1 State Vehicle

2 Other Vehicle

3 Third Vehicle

Indicate North Pedestrian

Stop Sign

Yield Sign

Stop Light

Scope of Employment Statement

As the driver of the state owned vehicle described in this report, I As supervisor of this position, I affirm that the individual named
acknowledge that all information provided is true and accurate to driver was operating the vehicle within his or her authorized scope
the best of my knowledge. of employment at the time of the accident. Yes No
Signature of Driver (Required) Date (mm/dd/ccyy) Signature of Supervisor (Required) Date (mm/dd/ccyy)