Incident Summary

Incident Location:

Incident Date:

Incident Type:

Date Safety Manager Notified:

Reported to Safety Manager by:

Supervisor Phone:

Brief Summary:

Location Type:

Type of Claim:

Responsible Party:
Vehicle Information

Number of Vehicles

Total Number of Vehicle Occupants:

Number of Vehicle Parties Injured:

Vehicle Injury Details:

Number of Vehicle Fatalities:

Other Vehicle Occupants:

Vehicle Damage Level:

Vehicle Damage Description:

Vehicle Damage Pictures
Drawing of Accident Scene

Vehicle Fender ID Numbers

Vehicle's Make / Model / Year

Vehicle VIN Numbers:

Vehicle License Plates:

Witness Information:

Add signature

Witness Information:

Add signature

Law Enforcement Notified?

Report Done?

Case / Incident:



Insurance Phone:

Insurance Policy Number:

Vehicle Make / Model / Year:

Vehicle License Plate:

DL / Registration / Insurance
Employee Detail

Employee Driver Last, First:

Employee ID Number:

Employee Driver License #

Drivers Date of Hire:

Employee Driver SSN:

Employee DOB:

Employee Drivers Status:

Accident Details

Accident Details:
Accident Type:
Weather Conditions:
Road Conditions:
W.C. Spratt, Inc. Vehicle Path:
W.C. Spratt, Inc. Vehicle Status:

Vehicle Monitoring:

Siren Detail:

Warning Light Detail:

W.C. Spratt, Inc. Speed Detail:
Intersection Detail:
W.C. Spratt, Inc.Backing Detail:

W.C. Spratt, Inc.Seatbelt Detail:

Vehicle Code:

W.C. Spratt, Inc. Policy:


Corrective Action:

Action Plan-Driver:

Date Completed-Driver:

Action Plan-Partner:

Drug Test (s) Performed within (2) hours of Incident:


Accident Scene Photos

Photos of Overall Scene
Drawing of Accident Scene

Crew Statements

Driver's Statement

Driver's Signature

Additional Passenger Statement

Additional Passenger Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.