Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
Employee Information
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Name of Driver:
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Date of Birth:
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Address of Employee:
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Employee Phone #:
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Drivers License #:
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Sex:
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Date Hired:
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Employment Status:
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If other, explain:
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Accident Date and Time:
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Time Employee Started Work:
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Passenger/Witness To Accident:
Vehicle Information
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Vehicle #:
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Vehicle Make:
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Vehicle Model:
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License Plate #:
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Any Damage to Vehicle:
Accident Information:
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Address of Accident:
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Was Any Property Damaged:
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If yes, property owner name:
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Property Owner Phone #:
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Property Owner Address:
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Was Another Vehicle Involved:
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If yes, driver name:
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If yes, driver phone #:
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If yes, driver address:
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Does other vehicle have damage:
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Make and Model of Vehicle:
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Name of Drivers Insurance Company:
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Insurance Company Phone #:
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Did either vehicle need towed?
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If yes, towing company name:
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Towing company phone #:
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Will repairs be needed:
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Were police/emergency crews on scene:
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If yes, officer name:
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Police claim/report #:
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Did anyone need emergency medical services:
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If yes, explain:
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Describe Accident:
Injury Information:
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Injury factor:
- Inclement Weather
- Excessive Speed
- Vehicle Malfunction
- Distractions
- Other
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Body part injured:
- Ankle
- Arm
- Back
- Ear
- Eye
- Face
- Finger
- Foot
- Hand
- Forehead
- Head
- Hip
- Knee
- Leg
- Mouth
- Nose
- Ribs
- Shoulder
- Teeth
- Toe
- Thumb
- Wrist
- Other
- N/A
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Indicate Left or Right:
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Type of Injury:
- Abrasion
- Burn
- Bruise/Contusion
- Cut/Laceration
- Dislocation
- Fracture
- Foreign Body
- Irritation
- Poisoning
- Sprain/Strain
- Other
- N/A
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Could this accident have been prevented:
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If yes, how:
Finalization:
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Report Prepared By:
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Signature:
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Title:
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Date:
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Report Reviewed By:
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Signature:
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Title:
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Date: