VEHICLE ACCIDENT INVESTIGATION REPORT

DEPARTMENT:

/

REPORT No:

PARTICULARS OF ACCIDENT

/ PART 1 - To be completed by driver
Date of Accident: / Time / am/pm / Usage: / Business / Private
Location: / Date Reported:
COMPANY VEHICLE: / Reg. No: / Make: / Current WOF:
Fleet No:
OTHER VEHICLE: / Reg. No: / Make: / Colour:
DRIVER’S NAME: / Telephone No:
Address:

COMPANY DRIVER DETAILS

Family Name: / First Name:
Date of Birth: / Occupation: / Length of Employment:
Current Driver’s Licence / Yes / No / Licence Number / Classes of Licence
Any drugs/liquor taken in 12 hours prior to accident? / Yes/No
If yes, how much?
Have you had a previous accident? / Yes/No
State brief details of previous accident(s):
Cost Centre you were based at the time of the accident:

NATURE OF INJURIES

1) To Driver:
2) To Passenger(s):
3) To third Party:
Is the Driver: / Off work? / Back to work?

DESCRIPTION OF ACCIDENT

SKETCH OF ACCIDENT SCENE
Who was at fault?
Who admitted liability?
Why?

WITNESSES TO ACCIDENT

Name: / Telephone:
Address:
Name: / Telephone:
Address:

GENERAL

Did a Police Officer attend? / Yes / No / Which Station?
Was a breath test taken? / Yes / No / Of whom?
Speed of your vehicle prior to accident: / Kph / At impact: / Kph
Road Surface: / Wet / Dry / Tar sealed / Loose Metal
Visibility: / Good / Fair / Poor
Were all seat belts correctly fastened in your vehicle? / Yes / No / Were your vehicle lights on? / Yes / No
Statistical Information
(Enter the number of the statement best describing the accident or conditions applying at the time)
Type of accident: / 1 Hit third party
2 Hit by third party
3 Hit stationery object
4 No other vehicle involved / 5 Vandalism
6 Windscreen Only
7 Theft
Company Vehicle was: / 1 Stationery
2 Moving Off
3 Slowing Down
4 Overtaking
5 Changing lanes
6 On a roundabout / 7 Making a “U” Turn
8 Reversing
9 Unattended
10 Intersection
11 Proceeding normally
DECLARATION
I hereby declare that the foregoing particulars are true to the best of my knowledge and belief and I undertake to assist the Company to the full in dealing with the matter and undertake to supply such additional information as may be required by the Company.
Certified correct: / SIGNATURE OF DRIVER: / DATE:
DAMAGED PROPERTY (Describe Damage) / PART 2 – TO BE COMPLETED BY MANAGER
Company Vehicle:
Where is the Company Vehicle now?
Other Vehicle:
Is any Police / Court action being taken as a result of this accident?

ESTIMATED COSTS OF DAMAGE

Vehicle / $ / Other Company Assets / $
Third Part Property / $ / Chemical Spill / $
Other Vehicle(s) / $ / Overhead Costs / $
TOTAL / $
ACCIDENT ANALYSIS - What were the causes of the accident?
PREVENTION - What action has been taken to prevent a recurrence? / ACTIONED / BY WHOM? / BY WHEN
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Manager’s Signature:

/ Date:

April 16 Version 6Vehicle Accident Investigation Report ~ Form 020

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