• SSI Auto Accident Report

  • Date of Accident*
     - -
     :
  •  -
  • Driver Hire Date*
     - -
  • Did the driver have permission to use the vehicle?*
  • Was our driver wearing their seat belt?*
  • Is the employee over 21 years of age?
  • Was our insured driver injured in the accident?*
  • Were there any passengers in the insured vehicle?
  • If there were passengers, were any of them injured?*
  • Did the airbags deploy?
  • Was a police report filed?
  • Were citations issued?
  • Was our vehicle towed?
  •  -
  • Were there any witnesses?
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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.

  • Date
     - -
     :
  • Did the employee (Driver) sustain any injuries?*
  • Did the employee (Passenger) sustain any injuries?*
    • ****INTERNAL OFFICE NOTES BELOW TO BE ADDED LATER**** 

    • ****INTERNAL OFFICE NOTES BELOW TO BE ADDED LATER****

  • Workplace Injuries

    Take the Right Steps.

     

    Injured Team Member

    5-STEP PROCESS

    1. In the case of life/limb-threatening injuries, call 911.
    2. Immediately notify your supervisor.
    3. With your supervisor, contact a safety coordinator.
    4. If seeking treatment, locate the nearest approved medical provider. If an approved provider is unavailable, use the closest urgent care clinic.
    5. Immediately after your medical visit, provide your Work Status Report to your supervisor and complete the Employee Statement page of this ART form. 

     

    FSMs and Managers

    5-STEP PROCESS

    1. With your team member, contact a safety coordinator.
    2. If off-site care is needed, arrange for the employee to be transported/escorted to the medical provider. 
    3. Notify a safety coordinator and administer a drug screen per the SSI policy.
    4. Complete the ART Form, Drug Screen, and Accident Investigation (AI) within 2 hours of any incident.
    5. Forward completed Work Status Form, Drug Screen, ART Form, AI Form, and Team Member statement to: accident@ssidish.com

    In the event of a medical emergency, you should call 911 immediately and then notify a Safety Coordinator and the Team Member's emergency contact.

    • Safety Coordinators 
      • Jerry Stivers -
        • 501-617-5247
        • jerry.stivers@ssidish.com 

       

      • John Loftin - 
        • 903-730-2271
        • john.loftin@ssidish.com

       

      • Christopher Noren - 
        • 918-210-2288
        • cnoren@sstarmgmt.com

       

      • Sara Cagle - 
        • 214-347-4470
        • sara.cagle@sstarmgmt.com
        • hr@ssidish.com
    • Section A - Driver Accident Data 
    • Date of Injury*
       - -
    •  :
    • Date Reported*
       - -
    •  -
    • Was there a witness?*
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Date*
       - -
    • Section B - Driver Information Release 

    • I hereby authorize Southern Star Inc. or any of its representatives to be furnished any information and facts regarding this injury, including reports and records, results of diagnosis, treatment and prognosis, estimates of disability, and a recommendation for further treatment. This information is to be used for the purpose of evaluating and handling my claim for injury as a result of an incident occurring on or about the above-noted date of injury and for no other purpose, now, or in the future.

    • Date*
       - -
    • Section C - Driver Accident Investigation (AI) 

    • Contributing Factors

    • Equipment

    • 1.1 Did any defect(s) in tools or equipment contribute to hazardous conditions (maintenance, guarding, etc.)?*
    • 1.2 Were correct tools, equipment and PPE specified for the task?*
    • 1.3 Were correct tools, equipment and PPE available for the task and used?*

    • Environment

    • 2.1 Was a pre-site survey inspection performed?*
    • 2.2 Were any hazards observed?*
    • 2.3 Were hazardous conditions a contributing factor? (lighting, slippery floor, noise, contaminants, chemicals, ventilation, temperatures, congestions, weather, production pressures)*
    • 3.1 Was the employee trained to do the job?*
    • 3.2 Did the employee follow the proper procedures?*
    • 3.3 Was an established safety rule violated?*
    • 3.4 Was the employee physically and mentally capable of performing the task?*
    • 4.1 Are the procedures for the job task appropriate? Written?*
    • 4.2 Is the job task performance routinely observed and reinforced?*
    • 4.3 Are the workplace conditions routinely inspected?*
    • 4.4 Are deficiencies documented and appropriately dealt with?*
    • 4.5 Are there any specific safety issues or concerns that require management intervention?*
    • 4.6 Was a drug screen performed?*

    • Prepare photos by writing the date on/near the drug screen and placing the employee's driver's license near the drug screen. Take and upload as many photos as needed to show the entirety of the drug screen below. 

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    • Date*
       - -
    • Section D - Driver Medical Treatment Refusal 
    • Is the employee refusing medical treatment at this time?*

    • I   *   *   , hereby decline medical treatment for the above-mentioned injury.

    • Date*
       - -
    • Date*
       - -
    • Section E - Driver Employment Statement 
    • 5.1 Do you recall anything unusual or unexpected that happened?*
    • 5.2 Are there work conditions which contributed to this injury?*
    • 5.4 When did you first notice the injury or illness?*
       - -
    • 5.8 When did you tell your manager/supervisor?*
       - -
    • 5.9 When did you first notice the pain?*
       - -
    • 5.10 Have you ever had this pain before?*
    • Date*
       - -
    • Employee Translator*
    • Date*
       - -

  • Workplace Injuries

    Take the Right Steps.

     

    Injured Team Member

    5-STEP PROCESS

    1. In the case of life/limb-threatening injuries, call 911.
    2. Immediately notify your supervisor.
    3. With your supervisor, contact a safety coordinator.
    4. If seeking treatment, locate the nearest approved medical provider. If an approved provider is unavailable, use the closest urgent care clinic.
    5. Immediately after your medical visit, provide your Work Status Report to your supervisor and complete the Employee Statement page of this ART form. 

     

    FSMs and Managers

    5-STEP PROCESS

    1. With your team member, contact a safety coordinator.
    2. If off-site care is needed, arrange for the employee to be transported/escorted to the medical provider. 
    3. Notify a safety coordinator and administer a drug screen per the SSI policy.
    4. Complete the ART Form, Drug Screen, and Accident Investigation (AI) within 2 hours of any incident.
    5. Forward completed Work Status Form, Drug Screen, ART Form, AI Form, and Team Member statement to: accident@ssidish.com

    In the event of a medical emergency, you should call 911 immediately and then notify a Safety Coordinator and the Team Member's emergency contact.

    • Safety Coordinators 
      • Jerry Stivers - 
        • 501-617-5247
        • jerry.stivers@ssidish.com 
      • John Loftin - 
        • 903-730-2271
        • john.loftin@ssidish.com

       

      • Christopher Noren - 
        • 918-210-2288
        • cnoren@sstarmgmt.com

       

      • Sara Cagle - 
        • 214-347-4470
        • sara.cagle@sstarmgmt.com
        • hr@ssidish.com
    • Section A - Passenger Accident Data 
    • Date of Injury*
       - -
    •  :
    • Date Reported*
       - -
    •  -
    • Was there a witness?*
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Date*
       - -
    • Section B - Passenger Information Release 

    • I hereby authorize Southern Star Inc. or any of its representatives to be furnished any information and facts regarding this injury, including reports and records, results of diagnosis, treatment and prognosis, estimates of disability, and a recommendation for further treatment. This information is to be used for the purpose of evaluating and handling my claim for injury as a result of an incident occurring on or about the above-noted date of injury and for no other purpose, now, or in the future.

    • Date*
       - -
    • Section C - Passenger Accident Investigation (AI) 

    • Contributing Factors

    • Equipment

    • 1.1 Did any defect(s) in tools or equipment contribute to hazardous conditions (maintenance, guarding, etc.)?*
    • 1.2 Were correct tools, equipment and PPE specified for the task?*
    • 1.3 Were correct tools, equipment and PPE available for the task and used?*

    • Environment

    • 2.1 Was a pre-site survey inspection performed?*
    • 2.2 Were any hazards observed?*
    • 2.3 Were hazardous conditions a contributing factor? (lighting, slippery floor, noise, contaminants, chemicals, ventilation, temperatures, congestions, weather, production pressures)*
    • 3.1 Was the employee trained to do the job?*
    • 3.2 Did the employee follow the proper procedures?*
    • 3.3 Was an established safety rule violated?*
    • 3.4 Was the employee physically and mentally capable of performing the task?*
    • 4.1 Are the procedures for the job task appropriate? Written?*
    • 4.2 Is the job task performance routinely observed and reinforced?*
    • 4.3 Are the workplace conditions routinely inspected?*
    • 4.4 Are deficiencies documented and appropriately dealt with?*
    • 4.5 Are there any specific safety issues or concerns that require management intervention?*
    • 4.6 Was a drug screen performed?*

    • Prepare photos by writing the date on/near the drug screen and placing the employee's driver's license near the drug screen. Take and upload as many photos as needed to show the entirety of the drug screen below. 

    • Browse Files
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    • Date*
       - -
    • Section D - Passenger Medical Treatment Refusal 
    • Is the employee refusing medical treatment at this time?*

    • I   *   *   , hereby decline medical treatment for the above-mentioned injury.

    • Date*
       - -
    • Date*
       - -
    • Section E - Passenger Employment Statement 
    • 5.1 Do you recall anything unusual or unexpected that happened?*
    • 5.2 Are there work conditions which contributed to this injury?*
    • 5.4 When did you first notice the injury or illness?*
       - -
    • 5.8 When did you tell your manager/supervisor?*
       - -
    • 5.9 When did you first notice the pain?*
       - -
    • 5.10 Have you ever had this pain before?*
    • Date*
       - -
    • Employee Translator*
    • Date
       - -
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