Painters USA Vehicle Accident Report

• Driver Name

• Conducted on

  Date

• Prepared by

• Location
  Address

If you are involved in an accident:

• First, assess the condition of any passengers in your vehicle,
  1. If there are injuries, request medical assistance immediately.
  2. Call the police- we want an accident report completed by the police no matter how minor the incident.
  3.Remove the vehicle from the street if leaving it there creates a safety hazard, but do not leave the scene of the accident until released by the police officer.
  4. Contact Field supervisor, Fleet Manager, HR Director and Safety Manager
  5. Complete the vehicle accident report at the scene if able to or as soon as possible.

DATES AND TIMES

• Date and time of Accident

  Date

• Date and time reported

  Date

DRIVER # 1 YOUR VEHICLE (Painters USA VEHICLE)

• Your Name

• Painters USA vehicle ID #:

• Make/Model:

• Damage to your vehicle, if yes, take photos if safe to do so.

  YES

  NO

• Add media

  Media

OTHER VEHICLES

• Is there a SECOND vehicle involved?

  YES

  NO

• Driver #2's Name, Street address, city, state, zip and phone number

• Driver #2's Vehicle - License Plate, VIN Number Year, Make, Model and color. Photo graph of these will suffice.

• Driver #2's Insurance Company name, policy number and phone number. Photo of insurance cert will suffice.

• Is driver #2 alleging damage to his/her vehicle?

  YES

  NO

• Take photos of vehicle, vehicle damage, license plate, and insurance card.

  Media

• Are there injuries from the SECOND vehicle

  YES

  NO

• Was an ambulance required?

  YES

  NO

• Provide any details you may have into who was injured and what their injuries appear to be.

• Is there a THIRD vehicle involved?

  YES

  NO

• Driver #3's Name, Street address, city, state, zip and phone number

• Driver #3's Vehicle - License Plate, VIN Number Year, Make, Model and color. Photo graph of these will suffice.

• Driver #3's Insurance Company name, policy number and phone number. Photo of insurance cert will suffice.

• Is driver #3 alleging damage to his/her vehicle?

  YES

  NO

• Take photos of vehicle, vehicle damage, license plate, and insurance card.

  Media

• Are there injuries from the THIRD vehicle

  YES

  NO

• Was an ambulance required?

  YES

  NO

• Provide any details you may have into who was injured and what their injuries appear to be.

POLICE INFORMATION

• Where Police involved

  YES

  NO

• Department

• Police Department Phone #

• Was a citation issued

  YES

  NO

• Select Driver #1 Driver #2 Driver # 3

  • Driver #1
  • Driver #2
  • Driver # 3

ACCIDENT DESCRIPTION

CONTRIBUTING FACTORS

• Weather

  Select Clear Cloudy Rain Snow/Sleet Fog/Smoke

  • Clear
  • Cloudy
  • Rain
  • Snow/Sleet
  • Fog/Smoke

• Visibility

  Select Sunglare Dawn Dusk Darkness Road lighted Road unlighted

  • Sunglare
  • Dawn
  • Dusk
  • Darkness
  • Road lighted
  • Road unlighted

• Roadway

  Select Dry Wet Ice/Snow Muddy Obstruction Concrete Asphalt Gravel Dirt/Sand Metal Surface

  • Dry
  • Wet
  • Ice/Snow
  • Muddy
  • Obstruction
  • Concrete
  • Asphalt
  • Gravel
  • Dirt/Sand
  • Metal Surface

• Road Characteristics

  Select Straight Level Curve Grade Turn Industrial Area Business Area Residential Area Rural School/Park/Zone

  • Straight
  • Level
  • Curve
  • Grade
  • Turn
  • Industrial Area
  • Business Area
  • Residential Area
  • Rural
  • School/Park/Zone

• Type of Location

  Select Street Freeway/Turnpike Bridge Intersection Crosswalk UnderpaSS Alley Parking Lot Loading Dock Driveway Railroad Crossing

  • Street
  • Freeway/Turnpike
  • Bridge
  • Intersection
  • Crosswalk
  • UnderpaSS
  • Alley
  • Parking Lot
  • Loading Dock
  • Driveway
  • Railroad Crossing

• Other Factors

  Select Truck Train Bus Tractor - Trailer Motorcycle Bicycle Animal Fixed Object Pedestrian Objects in Road Brake Lights Speed Failure to yield Improper Passing Stop Sign Traffic Sign Improper turn

  • Truck
  • Train
  • Bus
  • Tractor - Trailer
  • Motorcycle
  • Bicycle
  • Animal
  • Fixed Object
  • Pedestrian
  • Objects in Road
  • Brake Lights
  • Speed
  • Failure to yield
  • Improper Passing
  • Stop Sign
  • Traffic Sign
  • Improper turn

SIGNATURES

• Employee Name: (enter name then tap Signature and sign)

  Sign

• Employee Name

  Sign