Title Page
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Document No.
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Audit Title
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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
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Vehicle Accident Report
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Claim Number: ( Risk Dept Use only)
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Employee Name:
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Employee Classification:
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Time:
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Date:
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Department:
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District Number:
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City/Township:
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Location:
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Accident Summary Tell exactly what happened:
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Vehicle Number:
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Police Dept. and UD-10#
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State License Plate #
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Passengers Names:
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What purpose was the vehicle being used for:
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Describe apparent damage:
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Direction of travel:
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What side of the street:
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How far from the curb:
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At what speed per hour:
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Length of skid marks:
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Weather at the time of accident:
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Pavement condition at time of accident:
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Other Vehicle Information
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License Plate#: Vehicle make & Model:
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What statements, if any were made by person whose property was damaged?
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Employee Signature:
