Driver Exchange of Information Form

Driver Exchange of Information

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
DIVISION OF FLORIDA HIGHWAY PATROL
This form has been designed to assist all parties involved in making an incident report to their insurance company.




DRIVER 1

Name
    ____________________________________________________________________
Address
       _________________________________________________________________
City                                  State          Zip
    ________________________________        ________     _______________
Business                              Home 
  Phone (_____)_______________        Phone (_____)________________

Driver License No. and State ____________________________________________

Vehicle Owner


Name
    ____________________________________________________________________
Address
       __________________________________________________________________
City                                  State          Zip
    ________________________________        ________     _______________
Business                              Home 
  Phone (_____)_______________        Phone (_____)________________

Year and Make                       Tag No. and State
of Automobile ___________________                    ____________________

Insurance                                      Policy No.
  Company  ___________________________________           ________________




DRIVER 2

Name
    ____________________________________________________________________
Address
       _________________________________________________________________
City                                  State          Zip
    ________________________________        ________     _______________
Business Phone                        Home Phone
              (_____)_______________             (_____)________________

Driver License No. and State ____________________________________________

Vehicle Owner


Name
    _____________________________________________________________________
Address
       __________________________________________________________________
City                                  State          Zip
    ________________________________        ________     ________________
Business                               Home
   Phone    (_____)_________________   Phone  (_____)____________________

Year and Make                       Tag No. and State
of Automobile ___________________                    ____________________

Insurance                                      Policy No.
  Company  ___________________________________           ________________





ACCIDENT INFORMATION


Location of Accident                          City/State
Street                                                
    ________________________________________    _________________________


                   Time                   Date
                         _________________      ________________


WITNESS INFORMATION


_______________________________________________________________________________
Name and Address



_______________________________________________________________________________
Name and Address



_______________________________________________________________________________
Name and Address



INVESTIGATING OFFICER


Name:  _____________________________________________________________




Badge #  and Department: ___________________________________________


Was a Florida Traffic Accident Report completed by the Investigating Officer? Yes No


Was a traffic citation issued by the Investigating Officer? Yes No



Remarks (Optional)