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DA 2041 Rev. 12/98 ACCIDENT REPORT LOUISIANA STATE DRIVER SAFETY PROGRAM Submit report to ORM within 48 hours of accident SUPERVISOR TO COMPLETE FIRST 4 ITEMS 2. Person to Contact 5. State Vehicle Driver’s Name 3. Phone 4. Loc. Code 6. Personnel Number 1. Agency Name 7. Date of Accident 8. Time of Accident AM PM 9. Exact Location of Accident (Use street markers, mileage markers, etc., to pinpoint location) 10. DESCRIBE HOW ACC. HAPPENED 11.Seat Belt in Use Yes No STATE VEHICLE INFORMATION If other then vehicle damage, fill in as much as possible under “Other Vehicle” section substituting property owner information for vehicle driver. 12. State Vehicle Driver’s Address (Street No) City State Zip Code 13. Home Phone 14. Work Phone 16. Age 15. Driver’s License No. 17. Sex M 19. Year Vehicle 20. Make Vehicle 18. Vehicle’s Owner’s Name and Address F 21. Model Vehicle 24A. Where can the Vehicle be Seen ? 22. Body Type 23. Vehicle Lic. No. / Equip No. / VIN 24B. Describe Damage OTHER VEHICLE INFORMATION If more than one vehicle is involved, submit additional sheet with information on other vehicle(s). 26. Driver’s Social Security No. 27. Driver’s License No. 25. Other Vehicle Driver’s Name 28. Age 29. Sex --no longer required-30. Other Vehicle Driver’s Address (Street No.) City State 33. Vehicle Owner’s Name and Address (Street No.) 34. Year Vehicle 35. Make Vehicle Zip Code State City 36. Model Vehicle 37. Body Type M 31. Home Phone 38. Vehicle I.D. No. or Lic. No. F 32. Work Phone Zip Code 39. Where can the vehicle be seen ? 41. Policy No. 40. Other Vehicle Insurance Co. 42. Describe Damage 43.Estimated Amount $ INJURED 44. Name and Address 45. Phone 46. PED 47. Ins. Veh. 48. Other Veh. 49. Police Investigated ? 44. Name and Address 45. Phone 46. PED 47. Ins. Veh. 48. Other Veh. 49. Type Report 44. Name and Address 45. Phone 46. PED 47. Ins. Veh. 48. Other Veh. 49. Report No. (Item No.) 52. Phone 53. PED 53. Ins. Veh. 53. Other Veh. 53. (Specify) 52. Phone 53. PED 53. Ins. Veh. 53. Other Veh. 53. (Specify) Yes State No Sheriff WITNESSES OR PASSENGERS 50. Name and Address 51. Witness Passenger 50. Name and Address 51. Witness Passenger 54. State Driver’s Signature 55. Name of Driver’s immediate Supervisor and Phone No. Print Form Submit by Email City