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Vehicle Accident/Incident ReportTo Be Completed By Investigating SupervisorSection 1: Claim Information COMMENTS \* MERGEFORMAT Company NameDate ReportedTime Reported FORMTEXT ????? COMMENTS \* MERGEFORMAT FORMTEXT ????? COMMENTS \* MERGEFORMAT FORMTEXT ????? COMMENTS \* MERGEFORMAT FORMCHECKBOX A.M. COMMENTS \* MERGEFORMAT FORMCHECKBOX P.M.Person ReportingContact NumberReport Number FORMTEXT ????? COMMENTS \* MERGEFORMAT FORMTEXT ????? COMMENTS \* MERGEFORMAT FORMTEXT ????? COMMENTS \* MERGEFORMAT Section 2: Driver InformationDriver’s NameDriver’s License NumberDate of HireStart Time of Current Shift FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX A.M. FORMCHECKBOX P.M.Home AddressCity StateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Driver Injured?If Yes, Extent of InjuryDriver Taken to Hospital?WC Claim Filed? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX YES FORMCHECKBOX NOSection 3: Accident/Incident InformationDate of AccidentTime of AccidentCityState FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX A.M. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX P.M.Accident Location – Street Name or Highway NumberNumber of Vehicles InvolvedTime Dispatch NotifiedTime Supervisor Notified FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX A.M. FORMTEXT ????? FORMCHECKBOX A.M. FORMCHECKBOX P.M. FORMCHECKBOX P.M. FORMCHECKBOX Accident at Intersection: (Name of Intersecting Streets)OR FORMCHECKBOX Not at an IntersectionWeather/Road ConditionsLight Conditions FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Police Report Made?If Yes, Police Agency & Report #Officer’s Name & Badge #Photos Taken? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NOSection 4: Company Vehicle InformationVehicle Make & ModelYearVIN NumberVehicle NumberLicense Plate Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Parts of Vehicle Damaged (Area of Damage)Vehicle Towed?If Yes, Where was Vehicle Towed? FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ?????Section 5: Other Vehicle InformationOther Vehicle 1Driver’s NameDriver’s License NumberVehicle Insured?Insurance Policy NumberDriver’s Phone Number FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ?????AddressCityStateZip CodeType of Vehicle (Make, Model, Year) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Parts of Vehicle Damaged (Area of Damage)Vehicle Towed?If Yes, Where was Vehicle Towed?Injuries?Hospitalized? FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX YES FORMCHECKBOX NOCompany Name (If Applicable)Company Phone NumberAddressCityStateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Vehicle 2Driver’s NameDriver’s License NumberVehicle Insured?Insurance Policy NumberDriver’s Phone Number FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ?????AddressCityStateZip CodeType of Vehicle (Make, Model, Year) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Parts of Vehicle Damaged (Area of Damage)Vehicle Towed?If Yes, Where was Vehicle Towed?Injuries?Hospitalized? FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX YES FORMCHECKBOX NOCompany Name (If Applicable)Company Phone NumberAddressCityStateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Section 6: Witness InformationNamePhone NumberAddressCity StateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePhone NumberAddressCity StateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePhone NumberAddressCityStateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePhone NumberAddressCityStateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Section 7: Accident/Incident InvestigationDescribe What Happened (Refer to Vehicles by Number, and by name of Driver(s)) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Diagram of Accident INSTRUCTIONSDraw picture of roadway at place of accident. Number each vehicle and show direction of travel by arrow.ExampleSYMBOLS1.Vehicle4.Railroad2.Motorcycle5.Utility Pole 3.PedestrianSignaturesDriver Signature:Supervisor Signature:Date:Date:Section 8: Accident/Incident ClassificationCompany NameDateDriver’s Name FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Accident/Incident ClassificationAccident/Incident Description & Code: FORMTEXT ?????Description Codes1301 Mechanical1302 Struck Vehicle in Rear1303 Struck Parked Vehicle1304 Struck Pedestrian, Bicycle1305 Struck Animal or Object1306 Backed into Vehicle or Object1307 Intersection Accident1308 Head-On Collision1309 Sideswipe or Lane Change1310 Entering or Leaving Traffic Flow1311 Jackknife, Rollover, Overturned Vehicle1312 Runaway Vehicle1313 Ran Off Roadway1314 Insured Vehicle Causes Other Accident1315 Injured While Entering or Leaving Vehicle1316 Foreign Object Thrown1317 Struck Building or Overhang1318 Non-Contact Accident1319 Struck/Pulled Down Wires1320 Road Debris/Road Hazard1321 Accidental Disposal of Property/Object1401 Towing1402 Our Vehicle Struck in Rear1403 Our Vehicle Struck While Parked1404 Our Vehicle Struck by Object or Animal1405 Our Vehicle Struck by Runaway Vehicle1406 Fire1407 Malicious Mischief1408 Theft1409 Our Vehicle was backed into1410 Other – Comprehensive9999 Not Otherwise ClassifiedVehicle(s) Involved Company Vehicle FORMCHECKBOX YES FORMCHECKBOX NOVehicle Action: FORMTEXT ?????Vehicle Action Codes01 Going Straight02 Slowing/Stopping in Lane03 Stopped in Traffic Lane04 Passing/Overtaking Vehicle05 Leaving a Parked Position06 Parked07 Entering a Parked Position08 Trying to Avoid Pedestrian, Animal, Object, Vehicle, etc.09 Turing Right on Red10 Turning Right11 Turning Left of Red12 Turning Left13 Making a U-Turn14 Backing Up15 Changing Lanes or Merging16 Negotiating Curve – Right17 Negotiating Curve – Left98 Other99 UnknownOther Vehicle #1 FORMCHECKBOX YES FORMCHECKBOX NOVehicle Action: FORMTEXT ?????Other Vehicle #2 FORMCHECKBOX YES FORMCHECKBOX NOVehicle Action: FORMTEXT ?????Injuries and FatalitiesClassificationInjuries?Number of InjuriesFatalities?Number of FatalitiesCompany Employee(s) FORMCHECKBOX YES FORMCHECKBOX NO # FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO # FORMTEXT ?????Pedestrian(s) FORMCHECKBOX YES FORMCHECKBOX NO # FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO # FORMTEXT ?????Other Vehicle Occupant(s) FORMCHECKBOX YES FORMCHECKBOX NO # FORMTEXT ????? FORMCHECKBOX YES FORMCHECKBOX NO # FORMTEXT ?????Pedestrian Accident/IncidentPedestrian involved in the Accident/Incident? FORMCHECKBOX YES FORMCHECKBOX NOIf Yes, complete the section below.Pedestrian Actions Crossing Street – End Block FORMCHECKBOX Other (specify) FORMTEXT ?????Crossing Street – Mid Block FORMCHECKBOX Walking along Street FORMCHECKBOX Accident/Incident Additional Information WeatherLight ConditionsRoad SurfaceDOT ReportableNo Adverse Conditions FORMCHECKBOX Dawn FORMCHECKBOX Dry FORMCHECKBOX FORMCHECKBOX YES FORMCHECKBOX NORain FORMCHECKBOX Daylight FORMCHECKBOX Wet FORMCHECKBOX Sleet, Hail, Freezing Rain FORMCHECKBOX Dark – Street Lights FORMCHECKBOX Muddy FORMCHECKBOX Snow/Ice FORMCHECKBOX Dark – No Street Lights FORMCHECKBOX Snow Covered FORMCHECKBOX Drug Test RequiredFog FORMCHECKBOX Dusk FORMCHECKBOX Ice Covered FORMCHECKBOX FORMCHECKBOX YES FORMCHECKBOX NOOther (Specify) FORMTEXT ????? FORMCHECKBOX Plowed Snow FORMCHECKBOX Salted & Cindered FORMCHECKBOX Ice Patches FORMCHECKBOX Notes* Accident/Incident Description & Code: Classify the collision/incident from the Description Codes selection list.** Vehicle(s) Involved: Identify which vehicles were involved and select the associated vehicle action from the Vehicle Action Codes selection list.*** Injuries and Fatalities: There are three classifications of people listed. Identify which classifications suffered injuries or fatalities and how many of each.Section 10: Driver Statement Driver Name Date of IncidentName of Person Notified of Accident/Incident FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Description of Accident/Incident: Be specific. What happened? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SignaturesDriver Signature:Date: ................
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