EMPLOYEE AUTO ACCIDENT FORM
***Drivers of Koopman Lumber Vehicles will STILL be required to complete the hand written form attached to this task, and submit it to their Supervisor*** The Supervisor/Manager will then complete this JotForm, and attach the employee report and pictures for distribution.
PERSON SUBMITTING FORM:
Name:
*
First Name
Last Name
Email:
*
example@example.com
Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Store Location:
*
Please Select
Andover
Dennis
Fairhaven
Hudson
Indian Orchard
Milford
North Grafton
Pembroke
Sharon
Uxbridge
Uxbridge Paint
Whitinsville
Berlin, CT
Cheshire, CT
East Hampton, CT
Meriden, CT
Kitchen & Bath
Estimating & EWP
Purchasing
Whitinsville Store Admin
Sutton Admin
Marketing
Accounts Payable
Credit Dept
Human Resources
IT
Service Department
Lumber Sales
Inside Sales
Other
EMERGENCY INFO:
Did Police Arrive at Scene of Accident:
*
Please Select
Yes
No
Did Police Issue a Citation:
*
Please Select
Yes
No
Were Emergency Medical Technicians or Ambulance Called:
*
Please Select
Yes
No
EMPLOYEE INVOLVED IN AUTO ACCIDENT:
Name:
*
First Name
Last Name
Date of Accident:
*
-
Month
-
Day
Year
Date
Address of Accident:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
WITNESS NAME:
Name:
First Name
Last Name
WITNESS CONTACT INFO:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Address of Accident:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ATTACH EMPLOYEE ACCIDENT REPORT HERE:
Attach/Upload:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
ATTACH PICTURES OF EMPLOYEE AUTO ACCIDENT HERE :
Attach/Upload:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: