Information

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location

Employee Information

  • Name of Driver:

  • Date of Birth:

  • Address of Employee:
  • Employee Phone #:

  • Drivers License #:

  • Sex:

  • Date Hired:

  • Employment Status:

  • If other, explain:

  • Accident Date and Time:

  • Time Employee Started Work:

  • Passenger/Witness To Accident:

Vehicle Information

  • Vehicle #:

  • Vehicle Make:

  • Vehicle Model:

  • License Plate #:

  • Any Damage to Vehicle:

Accident Information:

  • Address of Accident:
  • Was Any Property Damaged:

  • If yes, property owner name:

  • Property Owner Phone #:

  • Property Owner Address:
  • Was Another Vehicle Involved:

  • If yes, driver name:

  • If yes, driver phone #:

  • If yes, driver address:
  • Does other vehicle have damage:

  • Make and Model of Vehicle:

  • Name of Drivers Insurance Company:

  • Insurance Company Phone #:

  • Did either vehicle need towed?

  • If yes, towing company name:

  • Towing company phone #:

  • Will repairs be needed:

  • Were police/emergency crews on scene:

  • If yes, officer name:

  • Police claim/report #:

  • Did anyone need emergency medical services:

  • If yes, explain:

  • Describe Accident:

Injury Information:

  • Injury factor:

  • Body part injured:

  • Indicate Left or Right:

  • Type of Injury:

  • Could this accident have been prevented:

  • If yes, how:

Finalization:

  • Report Prepared By:

  • Signature:

  • Title:

  • Date:

  • Report Reviewed By:

  • Signature:

  • Title:

  • Date:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.