Motor Vehicle Accident Report
CS Construction, Inc.
Date of Accident
*
-
Month
-
Day
Year
Date
Time of Accident
*
Hour Minutes
AM
PM
AM/PM Option
Location of Accident
*
Jobsite
Public Road
Describe Accident
*
Details Matter! Please Be Descriptive As Possible.
Exact Location
*
Intersection, Street Name, Etc.
Employee(s) Involved In Accident
List Driver, Passenger and Pedestrians
Other Vehicle(s) Involved In Accident
List Driver, Passenger and Pedestrians
Injuries (Employee & Others)
List All Injuries
Medical Treatment Provided
At Location
Taken To Hospital
None
Company Vehicle Number
EX: 2-114
Other Vehicle Year
Ex: 2003
Other Vehicle Make
Ex: Dodge
Other Vehicle Model
Ex: Charger
Other Vehicle License Plate
Please Include State Too!
Other Vehicle Insurance Company
Inc. Policy Number Too If Possible
Other Vehicle Insurance Company Phone Number
Phone Number of Insurance Company
Police Contacted
Yes
No
Visible Damage (CSCI)
List Company Vehicle Damage Only
Other Vehicle Damage
List Vehicle Damage By Other Party
What Caused The Accident?
Driver Written Statement (CS Employee)
Employee Name (Involved In Accident)
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Employee Signature (Involved In Accident)
Photo Upload
Browse Files
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Choose a file
Upload Photos of Accident Here
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of
Investigated By
First Name
Last Name
Investigated Date
-
Month
-
Day
Year
Date
Investigated Person Signature
Submit
Should be Empty: