General Information

Name of driver

Driver's license number

Car registration number

Injured Person Background

Identification number

Take photo of ID


Date of Birth

Telephone Number

Injury Details
Date and time of event

What part of the body was injured? Describe in detail

Take photo of the body part that was injured. Annotate as required

Describe fully how the accident happened?

Take photo of the surrounding

Were safety regulations in place and used?

What was wrong?

Witness Statements

Were there any witnesses?

Add witness


Enter witness name

Contact number

Witness statement

Witness signature
Emergency Services

Employee went to doctor/ hospital?

Doctor's Name

Hospital Name

Police were called to the scene

Police reference number

Sign off
Injured person (Full Name and Signature)
Fleet manager (Full Name and Signature)