Accident Preliminary Report

Date / Time *

Date

Time

Day of week

Total number of vehicles involved in accident *

Company *

Company driver name *

Phone number *

Truck or tractor number *

Trailer number

Have you properly set emergency warning devices?

Have you called the police? *

Have you been cited for a moving violation *

Have you called for medical assistance?

Accident location description (City, County, State, Cross Street, etc.)

Weather Condition

Condition of road

Description of accident *

Any fuel leakage from your unit?

Name of other vehicle driver

Make and model of other vehicle

Drivers license number of other driver

Registration number and state of other vehicle

Company employee

Company vehicle passanger

Occupants of other vehicles

Pedestrians

Where have injured persons been taken? (Hospital, City/State)

Have you secured witnesses names and addresses?

Can your unit proceed safely under its own power? *

Did accident damage cause ANY vehicle to be towed?

Person 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.

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