Telligent Masonry

Instructions

1. Stop immediately. Keep calm and be courteous.

2. Turn on your emergency flashers.

3. Send for help. Don’t go yourself. Call police.

4. Give reasonable help to injured. Do not move injured persons if likely to cause further injury.

5. Immediately notify your supervisor.

6. Obtain and record all the facts on this report.

7. Take photos of license, license plate and insurance of other drivers involved as well as damages to all vehicles involved.

8. Submit this form to your supervisor.

9. Do not make a statement of any kind to anyone other than police or representative of the company.

This report is to be completed if you are in an accident while driving a company vehicle or while driving your personal vehicle on company business.

Date Report *

Info Supplied By

Company Name *

Phone Number *

Date of Accident *

Time of Accident

AM PM

Location of Accident(include city and state)

COMPANY VEHICLE

Name of Driver

Date of Birth

Driver’s Address

Driver’s Telephone No

Drivers License Number

Company Vehicle Number (if applicable)

Purpose for which vehicle was being used

Vehicle Year

Make/Model

State

License Plate No.

Vehicle Identification No

Vehicle

Company Vehicle Personal Vehicle

Describe the Damage to the Vehicle

OTHER VEHICLE OR PROPERTY

Name of Driver

Date of Birth

Address

Driver’s Telephone No

Drivers License Number

Vehicle Owner’s Name

Owner’s Address (include city and state)

Insurance company

Agent name

Agent Address

Agent Phone No

Vehicle Year

Make/Model

State

License Plate No.

Describe the Damage to the Vehicle

Personal Injuries

Name

Address

Phone No.

Name

Address

Phone No.

Name

Address

Phone No.

Witness(es)

Name

Address

Phone No.

Name

Address

Phone No.

Name

Address

Phone No.

Diagram of Collision:

LIGHT(check one)

Dawn
Daylight
Darkness- street lights

Darkness-no street lights
Dusk

ROAD CHARACTER(check one)

Level
Hillcrest
On grade

Curve
Straight

WEATHER(check one)

Clear
Snowing

Raining
Fog

ROAD SURFACE(check one)

Dry
Wet
Snowy

Muddy
Icy

Law enforcement agency notified

Case number.

Citation issued, to whom and for what reason

Brief description of accident (give speeds, violations, etc.)

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. This authorization also applies to insurance companies, workers’ compensation carriers, and organizations administering benefit programs. This authorization will remain in effect throughout the investigation of this accident. A photocopy of this authorization will be as valid as the original.

First Name *

Last Name *

Employee Id

Date

Signature

Clear Signature

Upload Files :
(Upload only pdf or image file)

Foreman Email:

Other Email:

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VEHICLE ACCIDENT REPORT

Information