Title Page
ACCIDENT INSTRUCTIONS
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1. STOP AT ONCE! Check for personal injuries and call or send for emergency personnel (Police, Fire Dept., Ambulance)
2. Tactfully get the name and addresses of witnesses, using the space provided on this form.
3. Do not argue. Make no statement except to the proper authorities. Sign nothing except the official police reports.
4. Note all details and complete this report. Do not plead guilty to any charge without consulting with your safety personnel.
5. When police arrive, get the name and badge number of the officer and note it on this report.
IN THE EVENT OF A SERIOUS INJURY, CONTACT YOUR DIVISION SAFETY REPRESENTATIVE OR THE CORPORATE SAFETY DEPARTMENT IMMEDIATELY!!!
VEHICLE INFORMATION
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Division:
- Mid-Atlantic
- Northern California
- Southern California
- Southwest
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Job Number:
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Vehicle Number:
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Vehicle Year:
- 2004
- 2005
- 2006
- 2007
- 2008
- 2009
- 2010
- 2011
- 2012
- 2013
- 2014
- Other
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Enter Year:
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Vehicle Color:
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Enter Color:
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Vehicle Make / Model:
- Ford F-150 Truck
- Ford E-350 Van
- Ford E-350 Truck w/ Service Body
- Ford Ranger
- Ford Transit
- Ford Escape
- Ford Escape Hybrid
- Ford Fusion
- Ford Fusion Hybrid
- Toyota Camry
- Toyota Camry Hybrid
- Toyota Prius
- Toyota Tundra
- Nissan Titan
- Chrysler 300
- Other
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Enter Make / Model:
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VIN Number:
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License Plate Number:
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License Plate State:
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State:
DRIVER INFORMATION:
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Name:
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Address:
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City:
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State:
- CA
- DC
- DE
- MD
- NV
- PA
- TX
- VA
- WV
- Other
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State:
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ZIP Code:
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Home Phone Number:
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Work Cell Number:
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Driver's License Number:
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State:
- CA
- DC
- DE
- MD
- NV
- PA
- TX
- VA
- WV
- Other
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State:
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Were there any passengers in the vehicle with you?
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Passenger(s) Name(s) and Relationship:
OTHER DRIVER INFORMATION:
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Name:
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Address:
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City:
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State:
- CA
- DC
- DE
- MD
- NV
- PA
- TX
- VA
- WV
- Other
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State:
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Phone Number:
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Is the driver also the owner of the vehicle?
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Owner Name:
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Owner Address:
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City:
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State:
- CA
- DC
- DE
- MD
- NV
- PA
- TX
- VA
- WV
- Other
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State:
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Owner phone number:
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Vehicle Make / Model:
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Vehicle Color:
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License Plate Number and State:
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VIN Number:
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Other Driver's Insurance Company:
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Insurance Company Phone Number:
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Insurance Policy Number:
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Were there any passengers in the vehicle?
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Passenger(s) Name(s) and Relationship:
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Take a picture of insurance other driver's card:
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Is There a Second Vehicle Involved?
OTHER DRIVER (2) INFORMATION:
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Name:
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Address:
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City:
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State:
- CA
- DC
- DE
- MD
- NV
- PA
- TX
- VA
- WV
- Other
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State:
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Phone Number:
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Is the driver also the owner of the vehicle?
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Owner Name:
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Owner Address:
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City:
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State:
- CA
- DC
- DE
- MD
- NV
- PA
- TX
- VA
- WV
- Other
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State:
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Owner phone number:
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Vehicle Year:
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Vehicle Make / Model:
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Vehicle Color:
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License Plate Number and State:
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VIN Number:
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Other Driver's Insurance Company:
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Insurance Company Phone Number:
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Insurance Policy Number:
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Take a Picture of the Insurance Card:
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Were there any passengers in the vehicle?
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Passenger(s) Name(s) and Relationship:
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Is There a Third Vehicle Involved?
OTHER DRIVER (3) INFORMATION:
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Name:
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Address:
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City:
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State:
- CA
- DC
- DE
- MD
- NV
- PA
- TX
- VA
- WV
- Other
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State:
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Phone Number:
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Is the driver also the owner of the vehicle?
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Owner Name:
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Owner Address:
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City:
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State:
- CA
- DC
- DE
- MD
- NV
- PA
- TX
- VA
- WV
- Other
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State:
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Owner phone number:
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Vehicle Year:
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Vehicle Make / Model:
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Vehicle Color:
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License Plate Number and State:
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VIN Number:
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Other Driver's Insurance Company:
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Insurance Company Phone Number:
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Insurance Policy Number:
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Take a Picture of the Insurance Card:
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Were there any passengers in the vehicle?
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Passenger(s) Name(s) and Relationship:
POLICE INFORMATION:
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Officer's Name:
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Badge Number:
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Headquarters:
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Police Report Number:
INCIDENT INFORMATION:
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Enter Date and Time:
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Use "Locate Me" to determine location:
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Check ALL Weather Conditions Which Apply:
- Clear
- Cloudy
- Dark
- Day
- Fog
- Ice
- Rain
- Snow
- Twilight
- Wind
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Type of Road Surface:
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Condition of Road Surface (Check ALL that apply):
- Dry
- Icy
- Good
- Snowy
- Wet
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Direction of Your Travel:
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Your Speed (MPH):
- 0
- 1-5
- 5-10
- 10-20
- 20-30
- 30-40
- 40-50
- 50-60
- 60+
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Direction of Other Driver's Travel:
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Other Driver's Speed (MPH):
- 0
- 1-5
- 5-10
- 10-20
- 20-30
- 30-40
- 40-50
- 50-60
- 60+
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Is There Another Vehicle Involved?
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Direction of Other Driver's (2) Travel:
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Other Driver's (2) Speed (MPH):
- 0
- 1-5
- 5-10
- 10-20
- 20-30
- 30-40
- 40-50
- 50-60
- 60+
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Is There Another Vehicle Involved?
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Direction of Other Driver's (3) Travel:
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Other Driver's (3) Speed (MPH):
- 0
- 1-5
- 5-10
- 10-20
- 20-30
- 30-40
- 40-50
- 50-60
- 60+
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Describe Incident IN DETAIL:
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Take MULTIPLE pictures of the vehicle(s) and collision site:
DAMAGE DESCRIPTION:
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Describe in detail the damage to your vehicle:
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Is our vehicle safely drivable?
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Was your vehicle towed?
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Towed By (Name and Address):
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Towed to (Name and Address):
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Describe in detail the damage to the Other Driver's Vehicle::
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Is There Another Vehicle Involved?
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Describe in detail the damage to the Other Driver's (2) Vehicle::
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Is There Another Vehicle Involved?
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Describe in detail the damage to the Other Driver's (3) Vehicle::
PERSONAL INJURIES:
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Are you injured?
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Contact your Division Safety Manager for closest medical facility.
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Are there any other injuries?
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Injury 1:
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Name:
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Address / Phone Number:
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Description of Injury:
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Are there other injuries?
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Injury 2:
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Name:
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Address / Phone Number:
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Description of Injury:
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Are there other injuries?
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Injury 3:
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Name:
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Address / Phone Number:
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Description of Injury:
WITNESS INFORMATION
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Is there a witness to the incident?
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Witness 1:
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Name:
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Address / Phone Number:
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Is there another witness?
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Witness 2:
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Name:
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Address / Phone Number:
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Is there another witness?
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Witness 3:
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Name:
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Address / Phone Number:
DIAGRAM OF COLLISION:
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Use the "Sign" function to draw a diagram of the collision.
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Send audit IMMEDIATELY to Division Safety Manager
