Vehicle Accident/Incident Report Form

Vehicle Accident/Incident Report
Incident Date

MonthDayYear
Incident Time

Hour Minutes

AM/PM Option
Submitter Name

First NameLast Name
Home Branch Location:
Customer Name (enter N/A if not applicable):
PO/TD Number (enter N/A if not applicable):
Onsite contact (enter N/A if not applicable):
Where did this incident happen?
Type of incident (select all that apply)
Were there any injuries?
Were emergency services called?
Address Location of Incident
Include road name, direction traveling, and nearest intersection/offramp.
Address Map Locator
Road Type
Total Number of Vehicles Involved
Company and Third Party
Number of Company Vehicles Involved
Company Vehicle Number/s
List vehicle numbers separated by a comma
Are you the driver of the vehicle involved?
Name of Driver 1 (employee)

First NameLast Name
Driver 1 Ph. number
Please enter a valid phone number.Format: (000) 000-0000.
Vehicle 1 Year, Make, and Model
Vehicle 1 Lic. Plate Number
Driver 1 Documents

Driver's license, Registration, Proof of Insurance
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Name of Driver 2 (other employee or 3rd party)

First NameLast Name
Driver 2 Ph. number
Please enter a valid phone number.Format: (000) 000-0000.
Vehicle 2 Year, Make, and Model
Vehicle 2 Lic. Plate Number
Driver 2 Documents

Driver's license, Registration, Proof of Insurance
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Name of Driver 3 (employee or 3rd party)

First NameLast Name
Driver 3 Ph. number
Please enter a valid phone number.Format: (000) 000-0000.
Vehicle 3 Year, Make, and Model
Vehicle 3 Lic Plate Number
Driver 3 Documents

Driver's license, Registration, Proof of Insurance
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Was Police Contacted to Complete Report?
Reason for Not Contacting Police
Was a Police Report Completed?
Police Dpt. Entity Name
If not report available enter time of call and reason for no response.
Photo of Police Report

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Weather and Road Conditions (select all applicable)
Describe the accident with as much detail as possible. What you were doing leading to the accident and what happened after.
Include details such as where you were coming from and heading to, and direcction of travel.
Upload all photos or video of the accident scene, damages, or additional documents.

Keep video to no more than 1 min and no higher than 1080P
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Were there other witnesses present?
Witness 1 (other than drivers)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Witness 2 (other than drivers)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Submitter's Signature
Should be Empty: