Vehicle Accident Report
Name of Driver
*
First Name
Last Name
Fleet Unit #
*
Driver Personal Telephone Number
*
Please enter a valid phone number.
Date and Time of Accident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Accident location
*
Number of Passengers
*
Please Select
0
1
2
3
4
5
6
7+
Passenger Name (1)
First Name
Last Name
Passenger Address (1)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Passenger Name (2)
First Name
Last Name
Passenger Address (2)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Passenger Name (3)
First Name
Last Name
Passenger Address (3)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Passenger Name (4)
First Name
Last Name
Passenger Address (4)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Passenger Name (5)
First Name
Last Name
Passenger Address (5)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Passenger Name (6)
First Name
Last Name
Passenger Address (6)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Passenger Name (7)
First Name
Last Name
Passenger Address (7)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Travel
*
Weather Condition(s) at the Time of Accident
*
Were there other vehicles involved?
*
Yes
No
Description of other vehicle. Please include make, model and year.
*
Other driver's name
*
First Name
Last Name
Other driver's address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Were there additional passengers in the other vehicle?
*
Yes
No
Other driver's insurance info
*
Other driver's license plate
*
Did the police respond?
*
Yes
No
Name of officer
*
First Name
Last Name
What police department?
*
Phone Number
*
Please enter a valid phone number.
Was anyone injured?
*
Yes
No
Who was injured?
*
First Name
Last Name
Describe injuries
*
Was anybody transported by ambulance?
*
Yes
No
Please list their names
*
Name of medical facility transported to.
*
Was company vehicle towed?
*
Yes
No
Location if known.
*
Please upload any pictures you have taken of the company vehicle, other vehicles involved, as well as the general scene of the accident.
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Please include the details of the accident.
*
Driver's Signature
*
Supervisor's Signature
*
Please know that this report must be completed with 24 hours of the accident.
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