Information
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Employee name:
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Accident location:
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Day/time of the accident
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Investigation conducted
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Prepared by
Driver Information
Driver inormation
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Driver photo
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Driver name
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Phone number
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Home street address
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Home city
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Home state
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Home zip code
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Drivers license
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DL state
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Date of Birth (Month/Day/Year)
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Date of Hire (Month/Day/Year)
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SSN#
Accident Information
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Accident street address (Or closest geographical point)
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Add location description if needed
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Add location description if needed
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Number of vehicles involved
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Number of commercial vehicles involved
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How did the accident happen?
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Description of damage to Sysco property
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Add media
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Add media
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Description of damage to other property
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Add media
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Add media
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Weather Condition
- Clear
- Cloudy
- Fog, smog, smoke
- Rain
- Sleet, hail, freezing rain
- Snow
- Severe crosswinds
- Other
- Unknown
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If other, please describe. Otherwise type "N/A".
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Light condition
- Daylight
- Dawn
- Dusk
- Dark-lighted roadway
- Dark-roadway not lighted
- Dark-unknown roadway lighting
- Other
- Unknown
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If other, please describe. Otherwise type "N/A".
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Road conditions
- Concrete
- Asphalt
- Brick
- Gravel
- Dirt
- Other
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If other, please describe. Otherwise type "N/A".
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Was anyone transported by ambulance?
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By signing here, I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may subject me to disciplinary actions up to and including termination.
Vehicle Information
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Sysco tractor #
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Tractor license plate
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Tractor license state
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Tractor VIN
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Tractor year
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Tractor make
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Tractor model
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Description of damage to Sysco tractor
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Take photos of damage to tractor
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Sysco Trailer #
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Trailer VIN
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Trailer license plate
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Trailer license state
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Trailer Year
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Trailer Make
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Description of trailer damage
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Take photos of damage to trailer
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By signing here, I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may subject me to disciplinary actions up to and including termination.
Other Vehicle
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Were other vehicles involved in this accident? If no, scroll to the bottom and have the driver read and sign the statement.
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Driver name
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Drivers address
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Drivers license #
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Drivers license state
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Drivers Date of Birth (Month/Day/Year)
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Drivers phone #
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Take a picture of the driver or their state-issued drivers license
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Other vehicle year/make/model
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Vehicle license plate
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Vehicle license state
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Is the driver the registered owner of the vehicle? If no, who is the registered owner and what is their contact information?
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Enter owners information here if different than the driver. Otherwise type "N/A"
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Drivers insurance company name
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Drivers insurance policy #
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Insurance Expiration (Month/Day/Year)
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Add picture of vehicle registration and/or proof of insurance.
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Describe the damage to other vehicle(s). If none, type "N/A".
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Take photos of damage to other vehicle(s)
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Was law enforcement called to the scene?
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Police officers name, report number, and name of issuing agency
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Was the Sysco driver cited?
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Was there any property damage other than to the vehicles
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Take photos of all damage to other property.
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By signing here, I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may subject me to disciplinary actions up to and including termination.
