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)