Knoxville Police Department

Private Property Traffic Accident Report

Pursuant to TCA 55-10-106, (a) The driver of a vehicle involved in an accident resulting in injury to or death of any person or property damage
to an apparent extent of fifty dollars ($50.00) or more shall immediately by the quickest means of communication give notice of such accident to
the local police department if such accident occurs within a municipality, otherwise to the office of the county sheriff or the nearest office of the
state highway patrol.
(b) The requirements herein shall apply to accidents occurring upon highways and the premises of any shopping center, trailer park or any
apartment house complex, or any other premises which are generally frequented by the public at large.
Pursuant to TCA 55-10-107, (a) The driver of a vehicle which is in any manner involved in an accident resulting in bodily injury to or death to
any person, or in which damage to the property of any one (1) person, including the drivers, in excess of four hundred ($400) is sustained, shall
within twenty (20) days after such accident, forward a written report of such accident to the department of safety; provided, that persons making
written reports to the department pursuant to the provisions of 55-12-104 shall not be required to make any additional report pursuant to the
provisions of this section. (b) The requirements herein shall apply to accidents occurring upon highways and the premises of any shopping center,
trailer park or any apartment house complex, or any other premises which are generally frequented by the public at large.
Complete all sections below and exchange this report with the other driver or drivers involved. It is the responsibility of each driver to Contact his
or her insurance company and notify them of this accident. As stated above in TCA 55-10-107, if the damage sustained in this accident is over
$400.00, it is the responsibility of each driver to complete a State of Tennessee Proof of Financial Responsibility Form, and submit this form to
the Department of Safety within 20 days. Failure to submit this report will result in suspension of driving privileges pursuant to TCA 55-12-109.
State of Tennessee Proof of Financial Responsibility Forms are available at the following locations:
Knoxville Police Department
800 E Howard Baker Jr. Ave.
Knoxville, TN 37915

Tennessee Highway Patrol

7601 Kingston Pike
Knoxville, TN 37919

Location / Address of Accident ___________________________________________________________________________________________

Time of Accident ___________________________ Date of Accident ____________________________________________________________

Drivers Name ____________________________________________ Phone Number (H) ______________________ (W)__________________

Drivers address _______________________________________________________________________________________________________

Drivers License Number & State _____________________________________ Vehicle Tag # _____________________ State ______________

Owners Name ___________________________________________ Phone Number (H) _______________________ (W) _________________

Owners Address ______________________________________________________________________________________________________

Vehicle Make ___________________________ Vehicle Year _____________ Vehicle Model _________________ Vehicle Color___________

Damage to Vehicle _____________________________________________________________________________________________________

Insurance Company ______________________________________________________ Policy# _______________________________________

Passengers name and Phone Number

Witness name and Phone Number

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KP-PT-OPR (3/03)-069-Rl