Vehicle Accident Report Form

Date of Accident: __________________ Time of Accident: _____________

Location of Accident: ___________________________________________________________

Description of Accident: (when, where, how) _________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Were the police called to the accident:_______________________________________________
Was anyone cited for the accident: (attach report) _____________________________________
______________________________________________________________________________

The information below must be completed:

AGENCY VEHICLE:
Damage to Company Vehicle: _____________________________________________________
Vehicle Identification Number: ____________________ Make __________________
Name of Driver: ________________________________ Model _________________
Telephone number of driver (daytime):_______________________

OTHER VEHICLE:
Damage to Other Vehicle: ________________________________________________________
Vehicle Identification Number: ____________________ Make __________________
Name of Driver: ________________________________ Model __________________
Address of Driver: ______________________________________________________________
Telephone number of driver: (daytime): ______________________
Insurance Company:________________ Policy No._____________ Agent:_________________

Complete if OTHER vehicle owner is different from driver

Name of Vehicle owner ___________________________________________________
Address of vehicle owner _________________________________________________________
Telephone number (daytime): _______________________________

Driver Signature ___________________________________________ Date ______________

Supervisor Report
Was employee sent for post-accident drug and alcohol screen? ___Yes ___No
Was this a preventable accident? ___Yes ___No

Insurance Contacted? ___Yes ___No

Time and Date Insurance Carrier Notified _________, _________ Claim#__________________

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Complete if transporting passengers:
Injuries

Name Address Telephone Sex Age Injured Hospitalized Killed

Vehicle Operator

Pupil/Passenger

Pupil/Passenger

Pupil/Passenger

Pupil/Passenger

Pupil/Passenger

Pupil/Passenger

Pupil/Passenger

Pupil/Passenger

Pupil/Passenger

Pupil/Passenger
Other
Witness

Name Address Telephone Remarks

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