Vehicle Incident Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• 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 Incident Report

• Date of Occurrence

  Date

• Location of Occurrence: Street/ Hwy., City and State.

• Description of Incident (who, what, when, where...)

• 1. Employee's Name

  Paul Jackson

  Jim Jackson

  Lisa Jackson

  Steve Mathews

  J.B. McKinney

• 2. Other vehicle(s) involved?

  Yes

  No

• 2a. Other vehicle driver's name?

• 2b. Driver License Number

• 2c. State (where issued)

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming

• 2d. Picture of Insurance Card

  Media

• 2e. License Plate Number

• 2f. Type of Vehicle: Year, Make, Model, Color

• 3. Damage(s) to employee's vehicle?

  Yes

  No

• Description of damages (e.g. location on vehicle, extent of damage, etc.)

• 3a. Images of employee's vehicle

  Media

• 4. Damage(s) to other vehicle(s)?

  Yes

  No

• Description of damages (e.g. location on vehicle, extent of damage, etc.)

• 4a. Images of other person(s) vehicle(s)

  Media

• 5. Passengers in employee's vehicle

  Yes

  No

• 5a. How many?

  Select 1 2 3 4 5 6 7 8

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

• 5b. Passenger(s) Name(s)

• 6. Passenger(s) in other vehicle(s)?

  Yes

  No

• 6a. How many?

  Select 1 2 3 4 5 6 7 8

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

• 6b. Passenger(s) Name(s)

• 7. Injuries

  Yes

  No

• 7a. Person's Name and Description of Injury(s)

• 7b. Ambulance called?

  Yes

  No

• 7c. Name of Hospital injured person(s) are being taken to?

• 8. Employee's vehicle owned by

  Company

  Employee

• 9. Employee's vehicle being used for

  Business Use

  Personal Use

• 10. Witnesses?

  Yes

  No

• 10a. Names and Phone Number(s)