Accident Report

Vehicle Accident Report

Complete all applicable sections. This report must be submitted as soon as possible after the accident.

Report Information

Date Report Prepared *

Information Supplied By *

Company Name *

Company Phone *

Date of Accident *

Time of Accident *

Location of Accident (city, state, cross streets) *

Company Driver & Vehicle Information

Driver Name *

Driver DOB *

Driver Address *

Driver Phone *

Driver License No. *

Company Vehicle Number

Purpose Vehicle Was Being Used *

Year, Make, Model *

License Plate & State *

Vehicle Identification No. (VIN) *

Vehicle Type * Company Vehicle Personal Vehicle

Describe Damage to Company Vehicle *

Other Vehicle or Property

Other Driver Name

Other Driver DOB

Other Driver Address

Other Driver Phone

Other Driver License No.

Vehicle Owner (if different from driver)

Insurance Company

Insurance Agent Name, Address & Phone

Year, Make, Model

License Plate & State

Describe Damage to Other Vehicle

Injured Persons

Name

Address

Phone

Witnesses or Passengers

Name

Address

Phone

Accident Scene Sketch

Draw the accident scene below. Use solid lines for the path before the accident and dashed lines for the path after. Mark north direction and include street names.

Line Style:

Accident Conditions

Light Conditions *

Weather *

Road Character *

Road Surface *

Law Enforcement

Law Enforcement Agency Notified

Case Number

Citation Issued (to whom and for what reason)

Accident Description

Brief Description (include speeds, violations, etc.) *

Employee Signature

I authorize the release to my employer of all records relevant to this accident. It is understood that the company will use the information to verify who was at fault and determine my eligibility for appropriate benefits.

Employee Name *

Signature Date *

Employee Signature * (Sign below)