Collision statement generator — PDF

Enter the details after a collision and prepare a statement to sign. For two vehicles; copy the document, download TXT or save PDF through the print dialog.

For collisions without injuries when participants agree on events and responsibility. If someone is injured or needs urgent help, call 112. In a dispute or suspected crime, such as drink-driving, contact the police. Put safety first.

Document language: English

Document language

Choose the document language independently of the page language. The template still refers to Polish law. Your entered information and descriptions remain unchanged and are not translated.

Fields without an “optional” label are required.

Incident

Collision date

Collision time

Collision location: town, street, number / junction

A — at-fault driver and vehicle

Leaving the owner blank means the named driver owns the vehicle. Otherwise enter the owner or co-owners.

Full name

Residential address

Phone (Optional)

Driving licence: number, category, issuing authority (Optional)

Vehicle owner: full name / business and address (Optional)

Make and model

Registration number

Visible vehicle damage (if none, write “no visible damage”)

Vehicle A liability insurer

Vehicle A liability policy number

Vehicle A policy valid until (Optional)

B — affected driver and vehicle

Leaving the owner blank means the named driver owns the vehicle. Otherwise enter the owner or co-owners.

Full name

Residential address

Phone (Optional)

Driving licence: number, category, issuing authority (Optional)

Vehicle owner: full name / business and address (Optional)

Make and model

Registration number

Visible vehicle damage (if none, write “no visible damage”)

Events and cause: manoeuvres, travel directions, point of impact

Witnesses: names and contact details (Optional)

Additional information and list of attachments, e.g. photos or sketch (Optional)

I confirm that there are no injured people, the participants agree on the events and driver A acknowledges causing the collision.

Statement preview

Complete the form, confirm the scope and prepare the statement.

The generator only prepares a document template. The parties must independently verify its accuracy, legal compliance and suitability for the incident before signing.

How do you complete a collision statement?

Record the drivers, vehicles and at-fault vehicle's liability policy. Describe the manoeuvre, directions and damage to both cars clearly. Do not guess missing information. Add witnesses if available. Review the preview against the documents, print and sign copies for the participants. Photos and a sketch can be attached separately; the generator does not load files.

Questions and answers

Does the statement replace calling the police?

Not in every situation. This form is for an agreed account of a collision without injuries. Injuries, danger or suspected crime require more than paperwork. If responsibility is disputed, ask the police to intervene rather than pressure someone to sign.

How do I download the collision statement as PDF?

Complete the required fields and prepare the statement. In the preview choose “Print / save PDF”, then select PDF in the browser print dialog. The file is created on your device. You can also copy the text or download TXT.

Does this document submit a claim or guarantee compensation?

No. The generator prepares a document to review and sign. It does not determine fault, verify insurance or submit a claim. Send the statement and evidence to the insurer through its own channels. The insurer assesses liability and compensation.

Are personal details saved or shared in a link?

The form runs entirely in this browser tab’s memory. The tool does not send your input to a server or save it in links or persistent application storage. Copied text and downloaded documents contain your input — you decide who receives them. Changing the document language does not translate your descriptions.

Sources and guidance: PZU · Policja — PDF. Reviewed: 2026-10-07.