Form Center

2. 
3. Franklin County Department of Public Safety
   1488 Franklin Street
   Rocky Mount, VA 24151
   540-483-3091
5. REPORTING AGENCY'S INFORMATION
7. Agency Name*
8. Contact Person*
10. Agency Reference #*
11. Address*
12. City*
14. State*
15. Zip*
16. E-mail Address*
18. Cell Phone
19. Business Phone
20. Other Phone
22. ACCIDENT DETAILS
24. Accident Date & Time*
    Accident Date & Time

    Accident Date & Time
25. Accident Location*
27. Reported to State Police

    1. Yes
    2. No
28. Name of Police Department*
29. Police Report #*
31. Vehicle Driver*
32. Driver Contact Phone*
34. Vehicle ID #*
35. Vehicle License Plate*
36. Vehicle ID (VIN)*
38. Vehicle Current Location (for inspection)*
40. Accident Description*
44. OTHER DAMAGED PROPERTY
46. Other Vehicle Driver's Name*
47. Other Driver's Phone*
49. Other Driver's Street Address*
50. City*
51. State*
53. Zip*
54. Other Driver's Insurance Company*
55. Other Driver's Policy*
57. Other Property - Owner's Name*
58. Property Location*
60. Owner's Street Address*
61. City*
62. State*
64. Zip*
65. Extent of Property Damage*
67. WITNESSES/PASSENGERS
69. Name
70. Phone Number
71. Witness or Passenger

    1. Witness
    2. Passenger
72. Vehicle

    1. Agency Vehicle
    2. Other Vehicle
74. Name
75. Phone Number
76. Witness or Passenger

    1. Witness
    2. Passenger
77. Vehicle

    1. Agency Vehicle
    2. Other Vehicle
79. Name
80. Phone Number
81. Witness or Passenger

    1. Witness
    2. Passenger
82. Vehicle

    1. Agency Vehicle
    2. Other Vehicle
84. INJURED
86. Name
87. Phone
88. Vehicle

    1. Agency Vehicle
    2. Other Vehicle
89. Extent of Injury
91. Name
92. Phone
93. Vehicle

    1. Agency Vehicle
    2. Other Vehicle
94. Extent of Injury
96. Name
97. Phone
98. Vehicle

    1. Agency Vehicle
    2. Other Vehicle
99. Extent of Injury
101. REPORTING
103. Reported By Name*
104. Reported To Name*
106. Vehicle ID License Information
     The person filling out this form will need to call in or bring Driver's license numbers for the driver of both vehicles to the Franklin County Department of Public Safety.
108. Date Submitted*
     Date Submitted
Leave This Blank:


110. 1. Receive an email copy of this form.
111. Email address

     This field is not part of the form submission.

112. Submit

* indicates a required field