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Vehicle Accident

Home > Accident/Incident Reporting and Information > Vehicle Accident

Vehicle Accident

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Job Classification*

Driver's Report of Motor Vehicle Accident

Report to the Fleet Manager and your supervisor immediately; then, complete as much of the report as possible.

Name of Person Completing Report:

First Last

Date

MM slash DD slash YYYY

Where Accident Occurred

County:

City/State:

Road or Street:

At Intersection With:

If not at intersection:

Feet or Miles:

Direction:

Nearest highway, street, bridge, or other landmark:

When did accident occur?

Date

MM slash DD slash YYYY

Time

Hour

:

Minute

AM/PM

Number of vehicles involved:

Did police officer investigate?

If available, take a photo of their business card

Yes

No

Name of police department:

Police Report Number:

Police Offer Business Card:

Max. file size: 32 MB.

Kind of Accident

Deer Strick/Single Vehicle Accident

Multi Vehicle Accident

Were there any passengers/witnesses?

Yes

No

Vehicle #1 - Driver's TEI Vehicle

Immediate Supervisor

Driver's Name (Last, First, Middle)

TEI Vehicle #

Year

Make

Model

Was a citation issued to driver of TEI vehicle #1?

Yes

No

List citation(s)

Vehicle #2 and/or Other Party

Name

First Last

Phone

Driver/Pedestrian

Driver

Pedestrian

Male/Female

Male

Female

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have a photo of the insurance card?

Yes

No

Please upload insurance card here:

Max. file size: 32 MB.

The preferred method is to take a photo of the other parties insurance card. If you are unable to take a photo complete the following:

Insurance Company Name

Insurance Company Address

Insurance Effective Dates

Insurance Expiration Dates

Phone

Is the other party the owner of the vehicle?

Yes

No

Vehicle Owner's Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Vehicle Make

Year

Model & Type

Vehicle Identification Number (VIN)

License Plate

State

Was a Citation Issued to Driver #2?

Yes

No

List Citation(s) if Available to you

Vehicle Damage Location Indicator

Please indicate on the image below where the damage on the vehicles was sustained by clicking on the diagram. Re-click a circle if you would like to remove it.

Passenger(s)/Independent Witness

Complete to the best of your knowledge.

Name

First Last

Phone

Male/Female

Male

Female

Address

Street Address City State ZIP Code

Vehicle number as described in report:

Check all that apply:

Witness

Passenger

Helmet used

Wearing seat belt

Injured

Ejected

Were there any additional passengers/witnesses?

Yes

No

Name

First Last

Phone

Male/Female

Male

Female

Address

Street Address City State ZIP Code

Vehicle number as described in report:

Check all that apply:

Witness

Passenger

Helmet used

Wearing seat belt

Injured

Ejected

Name

First Last

Phone

Male/Female

Male

Female

Address

Street Address City State ZIP Code

Vehicle number as described in report:

Check all that apply:

Witness

Passenger

Helmet used

Wearing seat belt

Injured

Ejected

Was there any damaged property?

Yes

No

Damaged Property:

Check all that apply

Mailbox

Utility Pole

Traffic Control Light

Bridge/Overpass

Guard Rail

Government Property

Yard/Landscaping

Street Sign

Building

Damaged Customer Property:

Please describe:

Other Damaged Property:

Please describe:

Other Comments/Additional Vehicles/Passengers/Witnesses:

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Thompson Electric, Inc.
49 Northmoreland Avenue
Munroe Falls, Ohio 44262

Call: (330) 686-2300 Fax: (330) 686-2362

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