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:


  • Report Prepared By:

  • Signature:

  • Title:

  • Date:

  • Report Reviewed By:

  • Signature:

  • Title:

  • Date:

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