Vehicle Incident

Steps Yes No

1. First, assess the condition of

any passengers in your vehicle

2. Is this an Emergency? Call 911 Call Dir. Of ED. & LP. to report the

And then immediately call Dir. Of incident then

ED. & LP. Call the police - we want an accident report completed by the police, No

matter how minor the incident. Remove the vehicle from the street if

leaving it there creates a safety

hazard, but do not leave the scene of

the accident until released by the

police officer.

3. Complete the vehicle accident report at the scene if able to or

as soon as possible using template “Accident: Vehicle

Accident Report Form”

4. You may provide the other party involved in the accident with your name, the company name, the company phone number, vehicle identification and insurance information, BUT DO NOT ACCEPT RESPONSIBILITY OR ADMIT LIABILITY! This is a “legal call” that will be made after all information is obtained and the investigation is concluded

Please continue on below for a sample Incident Report. All completed Incident reports should look like the following:

John Doe Accident: Vehicle Accident Report Form Complete

Inspection score Failed items Created actions

88.89% 0 0

Please swipe your screen to the left to the last section of this report and read the Vehicle Accident

Report Tips before proceeding. After reading that section, swipe back to this section and continue.

Motor Vehicle Report involving: ( Type the Company Employee's Name who is the Driver.) John Doe

Document No.

000001

Company Vehicle Number

Number 3

Conducted on

31st Jan, 2020 9:01 AM MST

Location

Inverness Dr S Englewood

CO 80112 United States (39.55839642559424, -104.86289826974814)

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Audit 88.89% Vehicle Accident Report Form

If you are involved in an accident:

* First, assess the condition of any passengers in your vehicle.

* If there are injuries, request medical assistance immediately.

* Call the police- we want an accident report completed by the police no matter how minor the incident.

* Remove the vehicle from the street if leaving it there creates a safety hazard, but do not leave the

scene of the accident until released by the police officer.

* Contact the Director of Safety and Loss Prevention 303-550-5292

* Complete the vehicle accident report at the scene if able to or as soon as possible.

* You may provide the other party involved in the accident whit your name, the company name, the

company phone number, vehicle identification and insurance information, BUT DO NOT ACCEPT

RESPONSIBILITY OR ADMIT LIABILITY. This is a "legal call" that will be made after all information

is obtained and the investigation is concluded.

Vehicle Accident Report

Office use only (Claim#) Has a claim been filed? If Yes, please enter the claim number in the Notes Section.

Drivers Name

John Doe

Drivers License Number

12-123-1234

Registration Number

$CVPVC479NBO JS7MB6

Make and model and Year of the company vehicle

2007 chevy Silverado

Drivers Phone Number

123-345-6789

Where there any witnesses to the accident? Yes

Click add Witness for each witness to the accident.

Wittness

Wittness 1

Witness Name Bob Dobalina

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Witness Phone Number (123 )654-8765

Was the witness interviewed by the police? Yes

_____POLICE MOST BE CALLED_____

Name of responding Police Officer Barney Fife Badge # 4222450

Police report number

Ab-1232

Take pictures of both sides of the police report or any information given to you. Be sure that it is readable.

Unanswered

What do we need to do to obtain the police report?

Deputy Fife said this doc will be available online within 24 hours, at city of Denver website

http://denvergov.org/content/denvergov/en/police-department/records.html

Was it local police, County, or State Highway Dept. State Patrol

Was an ambulance called? Yes

Name of the Ambulance Company

Highland ranch

Give a brief description of the actions of the paramedics? (ie Did they transport anyone, did they check people out and leave, etc. ) CPR

Other Vehicle

Click add Vehicle and complete the boxes for each other vehicle involved.

Vehicle

Vehicle 1

Drivers Name Everett McGill

Is this person the owner of the vehicle? Yes

Enter the owners name, address and phone number. Everett McGill, 997 Osceola Way 80000

Drivers address, city and state

Englewood, Co.

Drivers Phone Number

(123) 435-6533

Drivers Insurance Company

Geico

Insurance Company Yes

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Take a picture of their insurance card. Be sure to zoom and make sure it is clear.

— Photos

Photo 1

Policy Number

3424456-QWERTY

Insurance Company Phone Number

8003459876

Drivers License State and Number

34-444-9876

Vehicle License Plate and State

ABC 123

Vehicle Make, Model, Year and Color

Chevrolet Silverado

Description of damage to this vehicle.

Dent in quarter panel back right

Insert pictures of vehicle

— Photos

Photo 2

How many people were in this vehicle? 3

Was anyone in this vehicle injured? No

Property Damage

Was their damage to any property other than vehicles? Yes

Address

123 Plymouth Drive

Owner

Wally Eaton

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Description of the damage. Bent parking sign

Insert pictures of the damage.

— Photos

Photo 3

Accident Information

Address or cross streets

Plymouth Drive and Ball Court

Weather Ice

Area Residential

Road Asphalt

Condition Slippery

Direction (YOU) North

Direction (OTHER) West

Speed: posted and actual (YOU) Yes

— Notes

Posted speed 30 MPH, my speed was 30 MPH

Speed: posted and actual (OTHER) Yes

— Notes

Posted Speed 30 MPH, their speed was 50 MPH

If Intersection Caution Signal

Brief description of the accident Yes

— Notes

T bone on right rear quarter panel

Accident Diagram

Draw detail sketch of accident. Show directions and position of vehicles involved. Show number of lanes,

traffic control, pedestrians, etc. Use this symbols. Your Vehicle (A), Other Vehicle(s) (1B, 2-B), Direction

(N, S, E or W), Stop Sign (S), Caution Signal (C), Yield (Y), Pedestrian (P), Railroad (RR)

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Diagram

Insert pictures of the accident, and be sure to include the entire area including multiple angles.

— Photos

Photo 4 Photo 5 Photo 6 Photo 7 Photo 8

Enter Your Name and then Sign

Employee Name

31st Jan, 2020 9:38 AM MST

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Vehicle Accident Report Tips In the event of an accident, please remember to: NEVER “make a Deal” for damages. NEVER leave the scene of even a MINOR accident. NEVER accept an offer of cash, check, or “private” settlement. NEVER disavow injury to you or your passengers. NEVER offer to pay ANYTHING even if you think you are at fault. NEVER administer first aid unless you are LICENSED to do so. ________________________________________

ALWAYS (when conditions permit) move to shoulder or other “SAFE AREA” to prevent further

damage. ALWAYS ask someone to summon police and seek medical assistance. Repeat at 5-minute

intervals. ALWAYS remember the 3 C’s: Remain CALM, COURTEOUS, and CONSISTENT in your

version of the accident.

ALWAYS obtain complete information from those involved. ALWAYS complete this report on the scene- not later on. ALWAYS obtain the names of witnesses including addresses and phone numbers. ALWAYS notify the owner of the car you are driving as soon as possible.

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Media summary 8 Photos

Photo 1 Photo 2

Photo 3 Photo 4

Photo 5 Photo 6

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Photo 7 Photo 8

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