Collision Reporting Form

Please fill out this form as completely as possible. Once submitted Safety will turn all of this information into the proper agencies. Thank you.

1Basic Information

2DOT Accident Determination

3Vehicle and Accident Descriptions

4Accident Photos and Witnesses

5Drug & Alcohol Screening Determination and Reporting Procedures

6Accident Review Page

HURRICANE ACCIDENT NUMBER
DOT REPORTABLE - This will only be filled out by Director or Senior Safety Manager once determination is made.

DOT REPORTABLE - This will only be filled out by Director or Senior Safety Manager once determination is made. YES NO
AUTO LIABILITY POLICY# ZACAT9266605
AFTER HOURS REPORTING
877-241-6121
Person Completing Form Person Completing Form First Last
BEFORE FILLING OUT THIS CHECKLIST - HAS THE DRIVER CALLED THE POLICE? IF NOT TELL HIM TO CALL THE POLICE AND REPORT THE ACCIDENT, THEN HAVE HIM CALL YOU BACK TO COMPLETE THIS FORM

CHECKLIST - Complete the following checklist with driver before filling out the this form.

BEFORE FILLING OUT THIS CHECKLIST - HAS THE DRIVER CALLED THE POLICE? IF NOT TELL HIM TO CALL THE POLICE AND REPORT THE ACCIDENT, THEN HAVE HIM CALL YOU BACK TO COMPLETE THIS FORM CHECKLIST - Complete the following checklist with driver before filling out the this form. Stop and Investigate Set Warning Devices - Flasher & Triangles Out Help the injured Protect your vehicle and cargo from theft and further damage Do not move your vehicle until police arrive Contact Supervisor as soon as possible Discuss Accident ONLY with Proper Authorites (never talk to the MEDIA) Obtain Names and Addresses of Witnesses (use witness cards) Complete Accident Scene card at the scene of the accident Comply with ANY required alcohol/drug test Return entire packet to Safety Department Make certain the Driver Logs the Accident On Duty Look for Fires and Extinguish-Remind Driver there are 2 Fire Extinguishers on the Truck Provide Instructions on what pictures to take - See Instructions Below Notify Safety Director, VP of Transportation and COO if there is a fatality or injury Notify CBCS Checklist Completed
Driver Name Driver Name First Last
Driver Phone Number Driver Phone Number - ### - ### ####
Truck Number:
Trailer Number:

Put trailer number even if there is no damage to the trailer or load. This is for insurance purposes. If the truck is bob-tailing, put in NO Trailer - Bobtail
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM
Location Address of Incident Location Address of Incident
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Roadway (Rt#, Street, Intersecting Hwy)
Landmarks (Near bridge, Mile post etc...)
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Collision Reporting Form

Collision Reporting Form

AUTO LIABILITY POLICY# ZACAT9266605 AFTER HOURS REPORTING 877-241-6121

AUTO LIABILITY POLICY# ZACAT9266605
AFTER HOURS REPORTING
877-241-6121