SSI Auto Accident Report

Driver Name*

First NameLast Name

Date of Accident*

DateHourMinutesAM/PM Option

Driver License #*

Driver Phone Number*

Area CodePhone Number

Driver Hire Date*

Date

OFFICE*

Accident Location Details*

ex. 5400 Block of Corner of West and East Streets near Wal-Mart store

Did the driver have permission to use the vehicle?*

YesNo

Was our driver wearing their seat belt?*

YesNo

Employee Title

(TECH, FSM, RM, TRAINER etc...)

What was the Employee doing at the time of the accident? (i.e. driving to next job, loading van, replen, lunch break, etc.) :

Weather Condition at the time of the accident

Wet, Dry, Foggy, Sunny, Overcast, Rainy, Ice

Speed Allowed

MPH

Speed of our vehicle

MPH

Speed of other vehicle

MPH

Road conditions

Sealed, Gravel, Dirt or Other

Other Contributing Factors?

Phone, GPS, Traffic Signals, etc.

Is the employee over 21 years of age?

YesNo

Was our insured driver injured in the accident?*

YesNo

Were there any passengers in the insured vehicle?

YesNo

If there were passengers, were any of them injured?*

YesNoN/A - No passengers

Did the airbags deploy?

YesNo

Our Vehicle VIN

Mileage at the time of the accident?

Was a police report filed?

YesNo

What police department?

Police Report #

Were citations issued?

YesNo

If "Yes", list citations issued and to whom:

Drivers Statement *

Was our vehicle towed?

YesNo

Location / Address of the place our vehicle is being towed?*

Other Driver Name

First NameLast Name

Other Driver Phone Number

Area CodePhone Number

Other Drivers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Vehicle Information:

Year, Make, Model, Color, VIN # etc.

Were there any witnesses?

YesNo

If "Yes", List Name(s) / Contact info and have them complete the Witness statement.

Driver Drug Screen Photo

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Photo of Witness Statement Form #1

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*email additional witness statements

Photo of Other Parties Insurance Card - Front

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Photo of Other Parties Insurance Card - Back

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Upload a Hand Drawn Diagram of the Accident

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(Draw an outline of vehicle locations, road layout, location and type of right-of-way signs, arrows to indicate vehicles’ movement(s), etc.):

Front Photo of our Vehicle (full front view)*

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Drivers Side Photo of our Vehicle (full side view)*

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Passengers Side Photo of Our Vehicle (full side view)*

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Rear Photo of Our Vehicle (full rear view)*

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Photo of our Vehicle VIN*

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Front Photo of Other Vehicle (full front view)

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Drivers Side Photo of Other Vehicle (Full side view)

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Rear Photo of Other Vehicle (Full Rear View)

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Photo of License Plate on our Vehicle (up close photo of license plate)

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Passenger Side Photo of Other Vehicle (Full side view)

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Additional Photos - Back up and take a picture of the entire accident scene (wide angle)

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Additional Photos - Wide Angle of other necessary on scene items.

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Enterprise Accident Services Phone #: 1-800-325-8838 opt 2 (Glass Repair, Body Damage, Accidents)

**for towing needs, or to open a claim with their internal vehicle accidents team. For our vehicle damage repair process. A claim must be called in for each accident.

ENTERPRISE CLAIM #

Call Enterprise to open the claim.

Employee Signature*

Date

DateHourMinutesAM/PM Option

Did the employee (Driver) sustain any injuries?*

YesNo

Did the employee (Passenger) sustain any injuries?*

YesNoN/A

SSI Auto Accident Report

Workplace Injuries

Take the Right Steps.

Injured Team Member

5-STEP PROCESS

FSMs and Managers

5-STEP PROCESS

Contributing Factors

Equipment

Environment

Workplace Injuries

Take the Right Steps.

Injured Team Member

5-STEP PROCESS

FSMs and Managers

5-STEP PROCESS

Contributing Factors

Equipment

Environment