Motor Vehicle Accident Report Form

Motor Vehicle Accident Report
Date of incident

MonthDayYear
Date
Hour MinutesAM/PM Option
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Load Number
Location or Account Name:
(Enter the description for the location or name of the account if the accident occurred at the account.)
Supervisor contacted
Police Investigation?
Police Dept. Name and Phone Number
Were you given a citation?
You must contact supervisor once investigation is complete.
Police Report Number
Code on the back of the card given to you by the officer.
Vehicle Information (you)
Vehicle #
License Plate #
Veh. Identification #
Veh. Make/Model
Briefly Describe Injuries
Your Injuries
Birth Date

MonthDayYear
Describe damage to your vehicle
Take Photo of your vehicle
Passenger Name
Passenger in your truck if you have one
Injured?
Briefly Describe Passengers Injuries
Other Persons Personal and Vehicle Information

(DRIVER OF VEHICLE #2. If the other driver is not avaible fill in required boxes with NOT AVAILABLE)
LIC. PLATE NUMBER
YEAR
MAKE/MODEL
VIN
DRIVERS NAME

First NameLast Name
Birth Date

MonthDayYear
LIC STATE
Phone Number
Format: (000) 000-0000.
GENDER
Address

Street Address

Street Address Line 2

CityState / Province

Zip CodeCountry
Describe Damage
Take Photo of other vechicle
Take Photo
Passenger Name

First NameLast Name
Injured?
Briefly Describe Injuries
Lights and Sirens Activated
Weather
Roadway Character
Light Conditions
Traffic Control
Road Surface
Traffic Conditions
Pre-Accident Vehicle Action (You)
Pre-Accident Vehicle Action (Them)
Address Responding to

STREET ADDRESS

INTERSECTING WITH

CITY/TOWN/VILLAGEState

Zip CodeCountry
Describe What Happened
Witness Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
ALT. Phone Number
Format: (000) 000-0000.
DOT Post Accident Criteria
Driver Name

First NameLast Name
Date of Loss

MonthDayYear
Date
Time Reported

Hour Minutes

AM/PM Option
Did the accident involve a commercial motor vehicle?
Did the acident occur on a public road?
Did the accident involve a fatality?
Was any vehicle involved in the accident required to be towed from the scene AND was the employee cited for a moving traffic violation?
Did any person involved in the accident require immediate medical treatment away from the scene of the accident AND was the employee cited for a moving traffic violation by law enforcement?
Employee Signature
Supervisor or Manager

First NameLast Name
Supervisor or Manager Signature
Should be Empty:

Motor Vehicle Accident Report

Vehicle Information (you)

Other Persons Personal and Vehicle Information

DOT Post Accident Criteria