Accident Reporting

Date of accident *

Time

Driver 1 first name *

Driver 1 last name *

Driver 1 Phone *

Driver 1 date of birth

Driver 1 street address *

City *

State *

Zip *

Driver 1 license number

Driver 1 license expiration

Driver 1 job title

Vehicle ID (VIN) #

Year/Make/Model

Vehicle Ownership Vehicle Ownership

Wearing seat belt

Yes

No

Using cell phone

Yes

No

Airbags deployed

Yes

No

Describe damage to the vehicle

Information about other vehicles

Driver 2 first name *

Driver 2 last name *

Driver 2 Phone

Driver 2 date of birth

Driver 2 street address

City

State

Zip

Driver 2 license number

Driver 2 license expiration

Driver 2 job title

Vehicle 2 ID (VIN) #

Vehicle 2 Year/Make/Model

Describe damage to vehicle 2

Vehicle 2 Insurance company

Vehicle 2 Insurance policy #

Vehicle 2 Insurance agent name

If any other vehicles or individuals were involved in the accident, please provide further information:

Information About the Accident

Description of the accident *

Nearest city/town *

Street address

State

Zip

Police involved *

Yes

No

Police dept. name

Officer name and badge #

Police report #

Information about injuries

If injuries were to the employee an employee injury/investigation report must be completed

First name of injured person

Last name of injured person

Address of injured person

Type of injury

Age

Gender

Male

Female

Traveling in your vehicle

Yes

No

Traveling in other vehicles

Yes

No

Pedestrian

Yes

No

Was the driver in control of the vehicle at the time of the incident

Yes

No

Were pictures taken *

Yes

No

Employee Vehicle Accident Review

(For reviewing all vehicle accidents. To be filled out by the driver. Not for claim purposes.)

Driver's first name

Driver's last name

Date of hire

Assigned office

Date of last driver training

Seat belts worn

Yes

No

Were you on the cell phone

Yes

No

Were there external causes of the accident (weather, road debris, etc.) that should be noted?

Did the other vehicle have an opportunity to avoid or prevent the accident?

Website/URL

Information about other vehicles

Information About the Accident

Information about injuries

Employee Vehicle Accident Review

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