MOTOR VEHICLE COLLISION REPORT - DDS Companies

• Location Address of Motor Vehicle Accident

• Map Location
  Address

• Report Prepared by:

• Date and Time of Incident

  Date

• DDS Reporting Office Location

  Select

• DDS Division

  Select

• DDS Vehicle ID

• What was the weather like at the time of the accident?

• Incident Severity

  Select

• Document Number

Motor Vehicle Collision

• DDS Vehicle Operator Name

• Describe the incident.

• Were there any injuries?

  Yes

  No

  N/A

• Type of Injury / Body Part(s) Affected

• Was the employee transported by an ambulance to the hospital?

  Yes

  No

  N/A

• Were the employee seen by a doctor about this incident?

  Yes

  No

  N/A

• Name and Phone Number of Treating Physician

Motor Vehicle Accidents Only

• Describe any damage to company vehicle.

• Was the company vehicle towed from the scene?

  Yes

  No

  N/A

• What garage/address/city/state

• Were the police called to the scene?

  Yes

  No

  N/A

• What city/town/state police

• Record police officers name and badge number.

• Were any citations issued to the DDS driver involved?

  Yes

  No

  N/A

• Please provide a copy to your supervisor

• Was a police report filed?

  Yes

  No

  N/A

• Please provide copy to your supervisor

• Describe damage to other vehicle(s).

• Record the other motor vehicle operators name and phone number.

• Record the other motor vehicle operators home address.

• Record the other vehicles make, model, and color.

• Record other vehicles license plate number.

• Record other vehicles insurance information (company name and policy number).

• Besides the driver, were there passengers in the other vehicle?

  Yes

  No

  N/A

• How many passengers? What are their names?

• Was the DDS employee sent for post-incident drug/alcohol testing?

  Yes

  No

  N/A

• Please enter any additional facts relevant to this incident.

• When available, provide insurance claim number.