IMPORTANT INFORMATION: The purpose of this form is for citizens to document and make a voluntary report of a vehicle collision with the Meridian Police Department. The police did not investigate this crash and no police action will be taken based on the information provided.

Was information exchanged between drivers?   

Was a police officer called to the scene?   
 
Collision Information
Collision Date/Time:
Date:   Time:       
 
Collision Location Type:
 
 
City:
    
State/Zip:
                           
 
 
Collision Description:
  
 
 
 
Driver/Vehicle #1 Information  (Your Vehicle, Unit #1)
Name Of Driver:
     
Driver Address:
         
City:
    
State/Zip:
                           
Driver's License #:
    
Date Of Birth:
        
Home Phone:
 

 
Registered Owner:
     
Registered Owner Address:
         
City:
    
State/Zip:
                           
Vehicle Lic. Plate#:
    
Vehicle Information:
 
 
Insurance Information:
 
Damage To Vehicle:
 
 
 
 
 
 
 
 
Other Person Involved #1 (Optional)
Other Person Vehicle/Unit:
 
Other Person Type:
 
Other Person Name
     
Other Person Phone:
 
Other Person Address:
         
City:
 
State/Zip:
             
 
Property Damage:
  
Damage Cost (Estimated):
$
 
 
 
 
 
 
 
Reporting Person's Information
 
Your Name:
     
Your Phone Number:
Your E-Mail Address:
Your Address:
         
City:
    
State/Zip:
                           
 
Notice: Filing a false police report is a crime. By submitting the driver's statement, you are stating that this is true and correct to the best of your knowledge.

        Electronic Signature:  
 
 
 
 
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