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 want an accident report completed by the police no matter how minor the incident.

• * 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 whit 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#)

  Yes

  No

  N/A

• Employee's Name

  Yes

  No

  N/A

• D.O.B.

  Yes

  No

  N/A

• Date of Occurrence

  Yes

  No

  N/A

• Time of Accident

  Yes

  No

  N/A

• Chose one

  AM

  PM

• Drivers License Number

  Yes

  No

  N/A

• State

  Yes

  No

  N/A

• Location of Occurrence: Street/Hwy

  Yes

  No

  N/A

• City

  Yes

  No

  N/A

• State

  Yes

  No

  N/A

• License plate # and State

  Yes

  No

  N/A

• Vin#

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• What are the damages to our vehicle.

  Yes

  No

  N/A

• Passengers

  Yes

  No

• How Many?

  Select 1 2 3 4 5 6 7 8

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8

• Injuries

  Yes

  No

• Vehicle Owned by:

  Company

  Employee

  Business use: Personal use

• Witnesses

  Yes

  No

• If yes please provide name and phone number

  Yes

  No

  N/A

_____POLICE MOST BE CALLED_____

• Police Report # or Case #

  Yes

  No

  N/A

• Where the report can be obtained and when.

  Yes

  No

  N/A

• Name of responding Police Officer

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Was an ambulance called?

  Yes

  No

• If yes what was the name

  Yes

  No

  N/A

Other Vehicle

• Driver's Name

  Yes

  No

  N/A

• Is this person the owner of the vehicle?

  Yes

  No

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

  Yes

  No

  N/A

• Address, city and state.

  Yes

  No

  N/A

• Phone number including area code.

  Yes

  No

  N/A

• Insurance Company

  Yes

  No

  N/A

• Policy#

  Yes

  No

  N/A

• Insurance Company phone #

  Yes

  No

  N/A

• Drivers License Number and State

  Yes

  No

  N/A

• Vehicle license plate number and state

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Description of Damage

  Yes

  No

  N/A

• Passengers

  Yes,No

• If yes, how many?

  Select 1 2 3 4 5 6 7 8 9

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9

• Injuries?

  Yes

  No

• Passengers Names

  Yes

  No

  N/A

Personal Injuries

• Name

  Yes

  No

  N/A

• Address

  Yes

  No

  N/A

• Description of Injury

  Yes

  No

  N/A

• Treated at

  Yes

  No

  N/A

• Name

  Yes

  No

  N/A

• Address

  Yes

  No

  N/A

• Description of Injury

  Yes

  No

  N/A

• Treated at

  Yes

  No

  N/A

• Name

  Yes

  No

  N/A

• Address

  Yes

  No

  N/A

• Description of Injury

  Yes

  No

  N/A

• Treated at

  Yes

  No

  N/A

• Name

  Yes

  No

  N/A

• Address

  Yes

  No

  N/A

• Description of Injury

  Yes

  No

  N/A

• Treated at

  Yes

  No

  N/A

• Name

  Yes

  No

  N/A

• Address

  Yes

  No

  N/A

• Description of Injury

  Yes

  No

  N/A

• Treated at

  Yes

  No

  N/A

Property Damage

• Owner

  Yes

  No

  N/A

• Address

  Yes

  No

  N/A

• Description of Damage

  Yes

  No

  N/A

Accident Information

• Select date

  Date

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

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

• Speed: posted and actual (OTHER)

  Yes

  No

  N/A

• If Intersection

  Stopligth

  Caution Signal

  Stop (4 way)

  Stop (3 way)

  Stop 2 (way)

• Brief description of the accident

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Add signature

  Sign

• Select date

  Date