Vehicle Accident Report Form

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Vehicle Accident Report Form

• If you are involved in an accident:

• * First, assess the condition of any passengers in your vehicle.

• * If there are injuries, request medical assistance immediately.

• * Call the police- we would like a police report

• * Remove the vehicle from the street if leaving it there creates a safety hazard, but do not leave the scene of the accident until released by the police officer.

• * Contact immediate supervisor/fleet/safety administrator.

• * Complete the vehicle accident report at the scene if able to or as soon as possible.

• * You may provide the other party involved in the accident with your name, the company name, the company phone number, vehicle identification and insurance information, BUT DO NOT ACCEPT RESPONSIBILITY OR ADMIT LIABILITY. This is a "legal call" that should be made by our insurance company's claims department.

Vehicle Accident Report

• Office use only (Claim#)

• CECCo Driver's Name

• Driver's contact info

• D.O.B.

• Date and time of incident?

  Date

• Drivers license number.

• State

• Location of Occurrence: Street/Hwy

• City

• State

• License plate # and state

• VIN #

• Type of Vehicle: Year, Make, Model, Color.

• What are the damages to our vehicle?

• Names of passengers

  Select 1. 2. 3. 4. 5.

  • 1.
  • 2.
  • 3.
  • 4.
  • 5.

• Injuries

  Select 1. 2. 3. 4. 5.

  • 1.
  • 2.
  • 3.
  • 4.
  • 5.

• Vehicle Owned or Leased by CECCo

  owned

  leased

  N/A

• Location of CECCo vehicle.

• Witnesses?

  Select Yes No

  • Yes
  • No

• If yes please provide name and phone number

Police information

• Police Report # or Case #

• Where the report can be obtained and when.

• Name of responding Police Officer

• Was it local police, County, or State Highway Dept?

• Was an ambulance called?

  Yes

  No

• If yes, what was the name ?

Other Vehicle

• Driver's Name

• Is this person the owner of the vehicle?

  Yes

  No

• If, not owners name and relationship to the driver.

• Address, city and state.

• Phone number including area code.

• Insurance Company

• Policy#

• Insurance Company phone #

• Drivers License Number and State

• Vehicle license plate number and state

• Type of vehicle, year,make, model and color

• Description of Damage

• Passengers?

  Yes

  No

  N/A

• If yes, how many?

• Injuries?

  Yes

  No

  N/A

• Passengers Names

  1.

  2.

  3.

  4.

  5.

Personal Injuries

• Name

• Address

• Description of injury

• Treated at?

Property Damage

• Owner

• Address

• Description of damage

Accident Information

• Location (street, highway, city, state, etc.)

• Weather

  Select Clear Fog Raining Sleeting Snowing Ice

  • Clear
  • Fog
  • Raining
  • Sleeting
  • Snowing
  • Ice

• Area

  Residential

  Commercial

  Rural

• Road

  Asphalt

  Concrete

  Gravel

• Condition

  Dry

  Wet

  Slippery

• Direction (YOU)

  Select North South East West Southeast Southwest Northeast Northwest

  • North
  • South
  • East
  • West
  • Southeast
  • Southwest
  • Northeast
  • Northwest

• Direction (OTHER)

  Select North South East West Southeast Southwest Northeast Northwest

  • North
  • South
  • East
  • West
  • Southeast
  • Southwest
  • Northeast
  • Northwest

• Speed: posted and actual (YOU)

• Speed: posted and actual (OTHER)

• If Intersection

  Stopligth

  Caution Signal

  Stop (4 way)

  Stop (3 way)

  Stop 2 (way)

• Brief description of the accident

Accident Diagram

• Draw detail sketch of accident. Show directions and position of vehicles involved. Show number of lanes, traffic control, pedestrians, etc. Use this symbols. Your Vehicle (A), Other Vehicle(s) (1B, 2-B), Direction (N, S, E or W), Stop Sign (S), Caution Signal (C), Yield (Y), Pedestrian (P), Railroad (RR)

• Diagram

  Drawing

Internal Accident Analysis

• Was this accident avoidable?

  Yes

  No

  N/A

• What action should have been taken to avoid the accident?

• What training needs to happen NOW to change driver attitudes/behaviors so that our company avoids this type of accident in the future?

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