MISSOURI STATE HIGHWAY PATROL
Request for Accident Report
(Please print all information)
Requestor Information
Date of Request:_____________________________
Requesting Agency (include branch):__________________________________________
Address and City:_________________________________________________________
Name of Requesting party (agent):____________________________________________
(Last name) (First name)
Telephone # of Requesting Party:_____________________________________________
Claim/Case Number:_______________________________________________________
Requesting Party Involvement: Please mark one of the following.
| _______ | Involved in accident |
_______ | Owner of vehicle involved |
| _______ | Family member of involved party |
_______ | Attorney |
| _______ | Insurance Company representative |
_______ | Physician of injured party |
| _______ | Member of street dept. of jurisdiction |
_______ | News media representative |
| _______ | Does not apply |
||
| _______ | Other (explain)_____________________________________________________ |
||
Accident Report Information
Date of Accident:________________________________
Complaint/Incident Number (if known):_______________________________________
Name of Driver/Owner:____________________________________________________
(Last Name) (First Name) (M.I.)
Name of Driver/Owner:____________________________________________________
(Last Name) (First Name) (M.I.)
Accident Location (County and Highway):_____________________________________
Price and Payment Information
ENCLOSE A SELF-ADDRESSED ENVELOPE
Mail to: Missouri State Highway Patrol
599 S. Mason Rd.
St. Louis, MO 63141
Basic Accident Report (1997 to present) Price: $3.25 each
Please make check or money order payable to: DPS-MO State Highway Patrol
(Cash not accepted)
Downloadable/Printable MSWord version - HERE
