Vehicle Accident Report (copy) (copy)

Vehicle Accident Report

VEHICLE ACCIDENT PROTOCOL

Location *

Widget

Custom widget — review for native equivalent.

Franchise Email *

example@example.com

Teammate Name *

Widget

Custom widget — review for native equivalent.

Teammate Email *

example@example.com

Teammate Phone Number *

Teammate Home Address *

Other Driver Name: *

Other Driver Phone Number *

Other Driver Home Address *

Truck Number *

Time

Date of Accident *

Day of the Week *

Time of Accident *

Purpose of the Travel: *

Location of Accident

Address *

VEHICLE INFORMATION

Company Vehicle Year: *

Vehicle Make: *

Vehicle Model: *

VIN Number: *

Company License Plate Number: *

Supervisor *

Supervisor Email

example@example.com

Was another vehicle involved? *

Yes No

Other Vehicle Year:

Vehicle Make:

Vehicle Model:

Vehicle License Plate:

State:

Other Driver's Name *

Phone Number

Address

Insurance Name & Policy Number:

Witness(es)

1. Name *

1. Phone Number

Injuries / Fatalities

Injured? *

Yes No

Taken to Hospital?

Yes No

1. Name

1. Phone Number

Injured?

Yes No

Taken to Hospital?

Yes No

2. Name

2. Phone Number

Conditions

Roadway: *

Dry Slippery Under Repair other

Were seat belts used during accident? *

Yes No

Driver Statement: (Describe in detail what happened such as were you moving or stopped, approximate speed at time of incident, other driver's impact on the accident, etc. provide accurate and clear factual details) *

Accident Details

Describe the damage to the company vehicle: *

Front of Vehicle

Side View 1

Side View 2

Back of Vehicle

Additional Photos

Was company vehicle towed? *

Yes No

Describe the damage to the other vehicle: *

Other Vehicle Front

Side View 1

Side View 2

Other Vehicle Back

Additional Photos

Was the other vehicle towed? *

Yes No

Was the Accident Reported to: *

County Sherriff Highway Patrol City Police No police report

Our driver receive a ticket or warning: *

Name of Department: *

Report number: *

Officer Name:

Pictures of police report/citation/business cards; any documentation from PD at the scene.

File Upload

Name *

Signature of Person Completing Form *

Title