• 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

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

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

  • 1. Employee's Name

  • 2. Other vehicle(s) involved?

  • 2a. Other vehicle driver's name?

  • 2b. Driver License Number

  • 2c. State (where issued)

  • 2d. Picture of Insurance Card

  • 2e. License Plate Number

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

  • 3. Damage(s) to employee's vehicle?

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

  • 3a. Images of employee's vehicle

  • 4. Damage(s) to other vehicle(s)?

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

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

  • 5. Passengers in employee's vehicle

  • 5a. How many?

  • 5b. Passenger(s) Name(s)

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

  • 6a. How many?

  • 6b. Passenger(s) Name(s)

  • 7. Injuries

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

  • 7b. Ambulance called?

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

  • 8. Employee's vehicle owned by

  • 9. Employee's vehicle being used for

  • 10. Witnesses?

  • 10a. Names and Phone Number(s)

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