CC/MC - MVA Investigation

• Conducted on

  Date

• Prepared by

• Location
  Address

Vehicle Accident Investigation

• Home Plant

  Select 0701 - DFW 0702 - Austin 0702 - Leander 0703 - San Antonio 0704 - Houston 0706 - Catarina 0707 - Tilden 0708 - Cuero 0709 - Corpus Christi 0710 - Laredo 0721 - Midland

  • 0701 - DFW
  • 0702 - Austin
  • 0702 - Leander
  • 0703 - San Antonio
  • 0704 - Houston
  • 0706 - Catarina
  • 0707 - Tilden
  • 0708 - Cuero
  • 0709 - Corpus Christi
  • 0710 - Laredo
  • 0721 - Midland

• Date & Time

  Date

• Date & Time Reported

  Date

• Avoidability

  Avoidable

  Unavoidable

  In-House Avoidable

  In-House Unavoidable

  3rd Party Responsible

• Address of Event

• Summary

• Insured Vehicle/Property Damage

Insured Vehicle Info

• Unit Number

• Year

• Make

• Model

• Description

Employee Information

• Employee Name

• Last 4 of SSN

• Date of birth

• Date of hire

• Address

• City

• State

• Zip

• Telephone

• Injury Description (if any)

Other Vehicle(s) involved

• Year

• Make

• Model

• Plate#

• Damage (if any)

Other Occupant Information

• Driver Name

• Phone Number

• Address

• City

• State

• Zip

• Insurance Company Name

• Insurance Company Phone Number

• Insurance Company Policy Number

• Injury (if any)

• Passenger

  Yes

  No

  N/A

• Passenger Name

• Passenger Number

• Injury Description

• Did Police Respond

  Yes

  No

  N/A

• Jurisdiction

  Yes

  No

  N/A

• Officer Name

  Yes

  No

  N/A

• Badge #

  Yes

  No

  N/A

• Report #

  Yes

  No

  N/A

Hazardous Vehicle Conditions

• Hazardous Vehicle Conditions

  Select No Unsafe Condition Defective Headlamp Defective Tail Lamps Defective Brake Lights Defective Turn Indicators Defective Wipers Defective Defroster/Heater Defective Horn Low Tire Pressure Tire Failure Brakes Out of Adjustment Other Mech. Failure Describe:

  • No Unsafe Condition
  • Defective Headlamp
  • Defective Tail Lamps
  • Defective Brake Lights
  • Defective Turn Indicators
  • Defective Wipers
  • Defective Defroster/Heater
  • Defective Horn
  • Low Tire Pressure
  • Tire Failure
  • Brakes Out of Adjustment
  • Other Mech. Failure Describe:

• Describe:

Unsafe Acts (Insured Driver)

• Unsafe Acts (Insured Driver)

  Select No Unsafe Condition Fog Rain Snow Ice High Winds Poor Visibility Other Contributing Weather Conditions Poor Ground Conditions Other Conditions Describe:

  • No Unsafe Condition
  • Fog
  • Rain
  • Snow
  • Ice
  • High Winds
  • Poor Visibility
  • Other Contributing Weather Conditions
  • Poor Ground Conditions
  • Other Conditions Describe:

• Describe

Hazardous Weather/Ground Conditions

• Hazardous Weather/Ground Conditions

  Select No Unsafe Act Failure to Follow Proper Procedures Improper Use of Equipment Failure to Use Safety Devices Operating at Unsafe Speed Failed to Stop Failed to Yield Following Too Closely Failure to Maintain Control Improper Backing Placed Vehicle In Unsafe Position Parked and Failed to Set Brakes Load Not Secure Failed To Comply With Traffic Instruction/Warning Device Driver Inattention Other Describe:

  • No Unsafe Act
  • Failure to Follow Proper Procedures
  • Improper Use of Equipment
  • Failure to Use Safety Devices
  • Operating at Unsafe Speed
  • Failed to Stop
  • Failed to Yield
  • Following Too Closely
  • Failure to Maintain Control
  • Improper Backing
  • Placed Vehicle In Unsafe Position
  • Parked and Failed to Set Brakes
  • Load Not Secure
  • Failed To Comply With Traffic Instruction/Warning Device
  • Driver Inattention
  • Other Describe:

• Describe

Vehicle Actions

• Vehicle Actions

  Select Going Straight Negotiating Curve Passing/Overtaking Another Vehicle Right Turn Left Turn Slowing Stopped Starting/Accelerating From Stop Entering Traffic Backing On Street Parked Ascending Hill/Grade Descending Hill/Grade Other Describe:

  • Going Straight
  • Negotiating Curve
  • Passing/Overtaking Another Vehicle
  • Right Turn
  • Left Turn
  • Slowing
  • Stopped
  • Starting/Accelerating From Stop
  • Entering Traffic
  • Backing On Street
  • Parked
  • Ascending Hill/Grade
  • Descending Hill/Grade
  • Other Describe:

• Describe

Collision Type

• Collision Type

  Select Head-On Rear-End Angle Sideswipe Same Direction Sideswipe Opposite Direction Vehicle Overturned Other Describe:

  • Head-On
  • Rear-End
  • Angle
  • Sideswipe Same Direction
  • Sideswipe Opposite Direction
  • Vehicle Overturned
  • Other Describe:

• Other

Roadway/Jobsite/Plant

• Roadway/Jobsite/Plant

  Select Interstate US Route State Route County Route Municipal Route Off Road Job-Site Plant

  • Interstate
  • US Route
  • State Route
  • County Route
  • Municipal Route
  • Off Road
  • Job-Site
  • Plant

• Roadway

  One Way

  Two Lane

  On/Off Ramp

  Four Lane

  Divided Roadway

Investigator

• Name

• Signature

  Sign

• Date

Employee Signature

• Add signature

  Sign

Picture(s)

• Photo(s)

  Media

• Photo(s)

  Media

• Photo(s)

  Media

• Photo(s)

  Media

• Photo(s)

  Media

• Photo(s)

  Media

• Photo(s)

  Media

• Photo(s)

  Media