Accident Preliminary ReportPlease enable JavaScript in your browser to complete this form.Date / Time *DateTimeDay of weekTotal number of vehicles involved in accident *Company *Freight LogisticsMidwest BulkWaste LinkChem-WashLaw TransportationCompany driver name *Phone number *Truck or tractor number *Trailer numberHave you properly set emergency warning devices?YesNoHave you called the police? *YesNoHave you been cited for a moving violation *YesNoHave you called for medical assistance?YesNoAccident location description (City, County, State, Cross Street, etc.)Traffic control at sceneSignal LightStop SignPolice OfficerWarning SignRR Lights/GatesRR CrossbuckWork ZoneOther ControlNo ControlWeather ConditionCondition of roadDescription of accident *Any fuel leakage from your unit?YesNoName of other vehicle driverMake and model of other vehicleDrivers license number of other driverRegistration number and state of other vehicleCompany employeeFatalityInjuryCompany vehicle passangerFatalityInjuryOccupants of other vehiclesFatalityInjuryPedestriansFatalityInjuryWhere have injured persons been taken? (Hospital, City/State)Have you secured witnesses names and addresses?YesNoCan your unit proceed safely under its own power? *YesNoDid accident damage cause ANY vehicle to be towed?YesNoPerson filling out report *Attach pictures, documents, etc. Click or drag a file to this area to upload. Attach pictures, documents, etc. Click or drag a file to this area to upload. Attach pictures, documents, etc. Click or drag a file to this area to upload. NameSubmit
