Information
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Audit Title
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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
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Personnel
Vehicle Accident Report Form
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If you are involved in an accident:
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* First, assess the condition of any passengers in your vehicle.
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* If there are injuries, request medical assistance immediately.
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* Call the police- we want an accident report completed by the police no matter how minor the incident.
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* 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.
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* Contact immediate supervisor/fleet/safety administrator.
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* Complete the vehicle accident report at the scene if able to or as soon as possible.
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* 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
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Office use only (Claim#)
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Employee's Name
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D.O.B.
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Date of Occurrence
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Time of Accident
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Chose one
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Drivers License Number
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State
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Location of Occurrence: Street/Hwy
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City
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State
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License plate # and State
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Vin#
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Type of Vehicle: Year, Make, Model, Color.
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What are the damages to our vehicle.
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Passengers
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How Many?
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
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Injuries
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Vehicle Owned by:
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Witnesses
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If yes please provide name and phone number
_____POLICE MOST BE CALLED_____
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Police Report # or Case #
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Where the report can be obtained and when.
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Name of responding Police Officer
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Was it local police, County, or State Highway Dept.
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Was an ambulance called?
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If yes what was the name
Other Vehicle
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Driver's Name
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Is this person the owner of the vehicle?
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If, not owners name and relationship to the driver.
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Address, city and state.
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Phone number including area code.
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Insurance Company
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Policy#
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Insurance Company phone #
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Drivers License Number and State
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Vehicle license plate number and state
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Type of vehicle, year,make, model and color
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Description of Damage
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Passengers
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If yes, how many?
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
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Injuries?
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Passengers Names
Personal Injuries
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Name
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Address
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Description of Injury
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Treated at
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Name
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Address
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Description of Injury
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Treated at
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Name
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Address
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Description of Injury
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Treated at
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Name
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Address
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Description of Injury
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Treated at
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Name
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Address
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Description of Injury
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Treated at
Property Damage
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Owner
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Address
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Description of Damage
Accident Information
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Select date
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Location (street, highway, city, state, etc.)
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Weather
- Clear
- Fog
- Raining
- Sleeting
- Snowing
- Ice
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Area
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Road
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Condition
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Direction (YOU)
- North
- South
- East
- West
- Southeast
- Southwest
- Northeast
- Northwest
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Direction (OTHER)
- North
- South
- East
- West
- Southeast
- Southwest
- Northeast
- Northwest
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Speed: posted and actual (YOU)
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Speed: posted and actual (OTHER)
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If Intersection
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Brief description of the accident
Accident Diagram
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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)
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Diagram
Internal Accident Analysis
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Was this accident avoidable?
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What action should have been taken to avoid the accident?
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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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Add signature
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Select date
