Title Page

  • Driver/Technician

  • Driver/Technician's Phone #

  • Office

  • Current work schedule

  • How many days since your last day off?

  • Conducted on

  • Prepared by

General Information

  • Date the incident happened

  • Who did you report the incident to?

  • Date and Time the incident was reported.

  • If the notification was not the same day as the incident, why?

  • Exact location of incident
  • Take photo of the location where incident happened. You should make this a long shot with all vehicles in the photo if possible.

  • Weather condition

  • Type of Road Surface

  • Condition of Road Surface

Vehicle Information

  • Van Number

  • Year and Make of Company vehicle

  • VIN

  • Take photo of license plate

  • Driver's Estimated Speed

  • Direction of Travel

Incident Information

  • Describe the incident

  • Describe the damages of vehicle

  • Take photo of vehicle showing the damage from a distance

  • Show a photo of the direction the driver was going and what they saw before the incident.

  • Take a photo of the damage up close

  • Take a picture of the details that explain the damage (More than one angle of the damage).

  • Provide detailed descriptions of the physical damages

  • Was there a collision?

  • Draw a diagram of collision

  • Provide details of the vehicle(s) involved

  • Describe the damages of other vehicle(s)

  • Show a photo of the direction the other driver(s) was going and what they saw before the incident.

  • Take photo of other vehicle(s) (back off and show the whole vehicle with the damage).

  • Take a picture of the damage close up.

  • Take a photo of the license plate(s) or any detail that explain the damage.

  • Provide detailed descriptions of the physical damages

  • After the incident, is the vehicle safely drivable?

  • Was the vehicle towed?

  • Take a picture of the tow truck, or a card, that identifies who towed it.

  • Where was it taken?

Passenger Profile

  • How many people are involved in the accident?

  • Was anyone injured?

  • List the names and contact information of the injured.

  • Was anyone transported to the hospital?

  • To which hospital were they taken?

Reporting Information

  • Name of Agency Reported to

  • Name of Officer

  • Was there a ticket written to either driver?

  • Who got the ticket? What was the reason for the ticket?

  • Take a photo of the ticket

  • If there was an exchange of information given, take a photo of it.

Recommendation

  • State some ways the incident could have been prevented.

Completion

  • Full Name and Signature of Driver

  • Full Name and Signature of Supervisor

  • When complete, this document should be emailed to: claims@drsinstall.com and your FSM

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.