COLLISION INFORMATION EXCHANGE FORM
Maryland State Police
1201 Reisterstown Road
Pikesville, Maryland 21208
Maryland state law requires that the driver of a vehicle involved in a collision provide to and obtain from the other party or parties the driver’s name, address, and license number; the vehicle’s license number; the name and address of the vehicle’s owner, the insurance company’s name and policy number; and the name and address of the insurance agent (if available).
MOVE IT is a public awareness campaign developed by the State of Maryland, Montgomery County, and Prince George’s County to increase service delivery to the citizens of the Washington Metropolitan Region and improve traffic safety.
Montgomery County Department of Police
2350 Research Boulevard
Rockville, Maryland 20850
Prince George's County Department of Police
7600 Barlowe Road
Landover, Maryland 20785
Keep this form in the glove compartment of your vehicle and refer to it if you are involved in a collision. This is not an official collision report, but can be filled out and used as a checklist to assure that you have all the information you will need on the other driver(s) and vehicle(s) involved in the collision for your insurance claim.
COLLISION LOCATION
Street Name(s):
Number of Vehicles Involved:
Weather/Road Conditions:
Collision Date: Time:
THE OTHER DRIVER’S
INSURANCE INFORMATIONInsurance Company:
Policy Number:
Agent’s Name:
Insurance or Agent Phone:
Insurance Expiration Date:
WITNESS INFORMATION
Name:
Phone:
Address:
Name:
Phone:
Address:
THE OTHER DRIVER’S INFORMATION
Driver's Full Name:
Address:
Home Phone:
Work Phone:
Date of Birth:
Driver's License Number:
State:
Expiration Date:
THE OTHER DRIVER’S VEHICLE INFORMATION
License Plate Number:
State:
Expiration Date:
Vehicle Year:
Make/Model:
Vehicle Color:
Vehicle Identification Number:
Owner's Full Name:
Address:
Home Phone:
Work Phone:
