Title Page
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Driver/Technician
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Driver/Technician's Phone #
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Office
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Current work schedule
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How many days since your last day off?
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Conducted on
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Prepared by
General Information
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Date the incident happened
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Who did you report the incident to?
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Date and Time the incident was reported.
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If the notification was not the same day as the incident, why?
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Exact location of incident
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Take photo of the location where incident happened. You should make this a long shot with all vehicles in the photo if possible.
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Weather condition
- Cloudy
- Clear
- Dark
- Fog
- Ice
- Rain
- Snow
- Twilight
- Windy
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Type of Road Surface
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Condition of Road Surface
Vehicle Information
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Van Number
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Year and Make of Company vehicle
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VIN
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Take photo of license plate
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Driver's Estimated Speed
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Direction of Travel
- North
- South
- East
- West
Incident Information
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Describe the incident
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Describe the damages of vehicle
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Take photo of vehicle showing the damage from a distance
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Show a photo of the direction the driver was going and what they saw before the incident.
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Take a photo of the damage up close
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Take a picture of the details that explain the damage (More than one angle of the damage).
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Provide detailed descriptions of the physical damages
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Was there a collision?
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Draw a diagram of collision
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Provide details of the vehicle(s) involved
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Describe the damages of other vehicle(s)
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Show a photo of the direction the other driver(s) was going and what they saw before the incident.
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Take photo of other vehicle(s) (back off and show the whole vehicle with the damage).
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Take a picture of the damage close up.
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Take a photo of the license plate(s) or any detail that explain the damage.
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Provide detailed descriptions of the physical damages
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After the incident, is the vehicle safely drivable?
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Was the vehicle towed?
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Take a picture of the tow truck, or a card, that identifies who towed it.
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Where was it taken?
Passenger Profile
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How many people are involved in the accident?
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Was anyone injured?
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List the names and contact information of the injured.
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Was anyone transported to the hospital?
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To which hospital were they taken?
Reporting Information
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Name of Agency Reported to
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Name of Officer
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Was there a ticket written to either driver?
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Who got the ticket? What was the reason for the ticket?
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Take a photo of the ticket
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If there was an exchange of information given, take a photo of it.
Recommendation
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State some ways the incident could have been prevented.
Completion
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Full Name and Signature of Driver
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Full Name and Signature of Supervisor
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When complete, this document should be emailed to: claims@drsinstall.com and your FSM
