Chaparral Energy Vehicle Accident Report

• Affected Employee

• Date and Time

  Date

• Prepared by

• Location
  Address

• Personnel

Vehicle Accident

• Employee Name

• What is the Chaparral vehicle number?

• Vehicle Make

• Vehicle Model

• Vehicle Year

• License Plate #

• Employees Supervisor

• Date & Time of the Incident

  Date

• Weather/Road Conditions

  Select clear foggy rainy snowy icy

  • clear
  • foggy
  • rainy
  • snowy
  • icy

• Accident Location

• Witness Name

• Witness Phone Number

• 2nd Party Name

• 2nd Party Address

• 2nd Party Phone Number

• 2nd Party Vehicle Make

• 2nd Party Vehicle Model & Year

• 2nd Party License Plate Number

• List the 2nd Party's Insurance Company.

• List the 2nd Party's Insurance Phone Number

• How many passengers were inside the vehicle at the time of the accident?

• Where there any injuries?

• List the Police Officers Name.

• Pictures

  Media

• Description of Accident