TO PASSENGERS AND OTHERS TO PASSENGERS AND OTHERS
My employer requires that I report details of all accidents. If you witnessed this My employer requires that I report details of all accidents. If you witnessed this
one, please assist me by writing your name below. Write a brief description one, please assist me by writing your name below. Write a brief description
of your version of the accident on the reverse side, even if you consider me of your version of the accident on the reverse side, even if you consider me
at fault. at fault.
Name _________________________________________________________ Name _________________________________________________________
Home Address ________________________________ Tel. ____________ Home Address ________________________________ Tel. ____________
Business Address _____________________________ Tel. ____________ Business Address _____________________________ Tel. ____________
Date _____________________ 20 _________ Date _____________________ 20 _________
3005 (1-14) 3005 (1-14)
TO PASSENGERS AND OTHERS TO PASSENGERS AND OTHERS
My employer requires that I report details of all accidents. If you witnessed this My employer requires that I report details of all accidents. If you witnessed this
one, please assist me by writing your name below. Write a brief description one, please assist me by writing your name below. Write a brief description
of your version of the accident on the reverse side, even if you consider me of your version of the accident on the reverse side, even if you consider me
at fault. at fault.
Name _________________________________________________________ Name _________________________________________________________
Home Address ________________________________ Tel. ____________ Home Address ________________________________ Tel. ____________
Business Address _____________________________ Tel. ____________ Business Address _____________________________ Tel. ____________
Date _____________________ 20 _________ Date _____________________ 20 _________
3005 (1-14) 3005 (1-14)
ACCIDENT DIAGRAM ACCIDENT REPORT FORM
Show names of streets, locations of vehicles, travel Keep this form in your vehicle.
directions of vehicles, and prominent objects. Complete the report in case of accident
and return promptly to:
Clearly indicate the direction of North.
_____________________________
DRIVER’S RESPONSIBILITY
Any driver involved in a traffic accident is responsible for
completing an accident report. Following an accident, the driver
must contact the Fleet Manager and collect all information
requested on the accident report form. Even minor incidents
should be brought quickly to management’s attention in order
to protect against potential claims.
Your accident report and conduct at the accident scene is very
important. What is said and done at the accident scene can
either help or hinder the successful settlement of an accident
case. All drivers must know and understand what to do and say,
and be equipped to handle situations as they arise.
The following steps should be taken at the scene of a traffic
accident in which you are involved:
1. Stop the vehicle immediately and shut off engine. Failure to
stop at the scene of an accident in which you are involved is
a criminal offense which may subject you to the penalty of
the law in addition to disciplinary action by your employer.
2. Turn on the 4-way flashers and (if available) set out
INSTRUCTIONS: emergency markers (reflectors or flares) in accordance with
DOT regulations — one marker 100 feet in each direction
1. Use solid line to show path of vehicle before accident. from the scene and one near the scene. If the accident
occurs near a curve or hill crest, set the markers further
2. Use dotted line to show path of vehicle after accident. away, but not further than 500 feet from the scene.
3. Number each vehicle and show direction of travel with an arrow. 1 3. Assist any injured person, but DO NOT move them unless
absolutely necessary to prevent further injury (i.e., from
4. Show pedestrians with an X. fire). Keep any injured person as warm and quiet
as possible while waiting for the arrival of
emergency personnel.
Police Officer Information 4. See that help, such as police and ambulance are summoned
to the scene.
Accident Report Number
5. If you are the victim of a hit-and-run, or if the other party
Provided compliments of: of an accident refuses to remain at the scene or give you
information, notify the police and give them all the details
Officer Name(s) & Badge Number(s) you can. This way, your report is kept on the police log and
protects you if the other party tries to make a claim against
you at a later date.
6. Be polite. Provide only the information on your drivers
license and the insurance card in your accident packet.
Do not offer information concerning the accident to anyone
except the police.
7. Complete the accident report form and return it to the Fleet
Manager as promptly as possible. The following information
3005 (1-14) must be recorded.
THE ACCIDENT DAMAGE TO PROPERTY INJURED PERSONS
G A.M. OF OTHERS
Date: _________ Hour: _______________ G P.M. Name: ________________________________
Name of owner: _________________________
Location: ______________________________ Address: ______________________________
Address: ______________________________
On which side of the
street were you? ________________________
Nature of injuries: _______________________
Driving which way? ______________________ Name of driver: _________________________
How far from curb? ______________________
Where taken
Did you sound horn? G Yes G No Address: ______________________________ after accident: __________________________
Were your lights lit? G Yes G No
Condition of weather:_____________________ Driver’s By Whom: _____________________________
License No.:____________________________
Attending
Nature of Damage: ______________________ Physician: _____________________________
Road conditions: ________________________
Address: ______________________________
Describe how
accident occurred: _______________________
Name of owner: _________________________ Name: ________________________________
Address: ______________________________ Address: ______________________________
Name of driver: _________________________ Nature of injuries: _______________________
Address: ______________________________ Where taken
after accident: __________________________
Driver’s
License No.:____________________________ By Whom: _____________________________
Nature Attending
of Damage: ____________________________ Physician: _____________________________
Address: ______________________________
