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Report An Accident/Incident/Injury
Report An Accident/Incident/Injury
Call 911 if immediate medical attention is needed.
Step 1 of 2 - Personal Details
0%
This Was An
*
Accident
Incident / Near Miss
Injury
A motor vehicle accident is defined as "any occurrence involving a motor vehicle which results in death, injury, or property damage.
An instance of something happening, either an expected or unexpected event or occurrence that doesn't result in an injury or accident. A "near miss" is defined as a narrowly avoided accident or injury.
Select this option if you need to report unsafe working conditions.
Damage, harm, or loss, to a person particularly as the result of external force. This injury did not occur while driving. If injured due to an accident when operating a motor vehicle, select the “Accident” option.
Driver Information
F|Staff Driver Name
*
F|Staff Driver Phone Number
*
F|Staff Driver Email
*
Customer Information
Customer
*
Customer Contact
*
Customer Contact Phone Number
*
Step 2 of 2 - Accident Details
50%
Vehicle Information
Company Vehicle Year
*
Company Vehicle Make
*
Company Vehicle Model
*
Truck Number
*
Trailer Number
*
Damage To Customer Vehicle
*
Third Party Information
Was there a third party involved?
*
Yes
No
Third Party Name
*
Third Party Phone Number
*
Third Party Email
*
Third Party Vehicle Year
*
Third Party Vehicle Make
*
Third Party Vehicle Model
*
Third Party Vehicle Color
*
Third Party Vehicle Damage
*
Third Party Insurance Name
*
Third Party Policy Number
*
Accident/Incident Information
Date of accident/incident
*
Date Format: MM slash DD slash YYYY
Time of accident/incident
*
:
HH
MM
AM
PM
Location of the accident
*
(MUST INCLUDE City, State and Specific location ie; warehouse, yard, street, highway, etc.)
Description of the Accident/Incident
*
Is the Commercial Motor Vehicle Drivable?
*
Yes
No
Has the Customer been notified?
*
Yes
No
Are There Any Injuries?
*
Yes
No
Who Are You Reporting This Injury For?
Myself
Someone Else
Injured Person's Name
Injured Person's Phone Number
Injured Person's Email
Did You Report The Injury To The Customer At The Jobsite?
Yes
No
To Whom?
Preferred Form of Contact
Medical Attention
Was An Ambulance Called?
Yes
No
Were You Taken To A Hospital?
Yes
No
Hospital Name
Hospital Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Description Of Events Leading Up To and Following Injury
What Parts Of Your Body Were Injured?
What Could Have Been Done To Avoid This Injury?
Police Information
Were the police notified?
*
Yes
No
Police Municipality
*
Police Municipality Phone Number
*
Officer Name
*
Officer Badge Number
*
Witness Information
Were there witnesses?
*
Yes
No
Witness Name
*
Witness Phone Number
*
Witness Email Address
*
Additional Information
Were you cited?
*
Yes
No
What Were You Cited For?
*
Please upload a copy of report
*
Drop files here or
Accepted file types: jpg, gif, png.
Did you go through a DOT Inspection?
*
Yes
No
Please upload a copy of the inspection report
*
Drop files here or
Accepted file types: jpg, gif, png.
Additional Comments
Incident Images
Drop files here or
Accepted file types: jpg, gif, png.
Please Draw Details Of Accident
Click on the Edit pencil on the bottom of the picture to begin drawing. When complete, click on the "done" button in the top right to save your edits.
F|Staff Driver Signature
*
Step 2 of 2 - Incident/Near Miss Details
50%
Incident Report / Near Miss
Date of Incident
Date Format: MM slash DD slash YYYY
Time of Incident
:
HH
MM
AM
PM
Location The Incident Took Place
*
(MUST INCLUDE City, State and Specific location ie; warehouse, yard, street, highway, etc.)
Are you reporting unsafe working conditions?
Yes
No
Witness Information
Were there witnesses?
*
Yes
No
Witness Name
*
Witness Phone Number
*
Witness Email Address
*
Witness Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Police Information
Were the police notified?
*
Yes
No
What We Were You Cited For?
Please upload a copy of report
*
Drop files here or
Accepted file types: jpg, gif, png.
Officer Name
*
Officer Badge Number
*
Department
*
Were you cited?
*
Yes
No
Incident Details
Incident Description (Including Any Events Leading To Or Following The Incident)
Resulting Action Executed, Planned Or Recommended
F|Staff Driver Signature
*
Step 2 of 2 - Injury Details
50%
Injury Report
Date of Injury
Date Format: MM slash DD slash YYYY
Time of Injury
:
HH
MM
AM
PM
Location The Injury Took Place
*
(MUST INCLUDE City, State and Specific location ie; warehouse, yard, street, highway, etc.)
Who Are You Reporting This Injury For?
Myself
Someone Else
Injured Person's Name
Injured Person's Phone Number
Injured Person's Email
Did You Report The Injury To The Customer At The Jobsite?
Yes
No
To Whom?
Preferred Form of Contact
Medical Attention
Was An Ambulance Called?
Yes
No
Were You Taken To A Hospital?
Yes
No
Hospital Name
Hospital Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Witness Information
Were there witnesses?
*
Yes
No
Witness Name
*
Witness Phone Number
*
Witness Email Address
*
Witness Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Incident Details
Description Of Events Leading Up To and Following Injury
What Parts Of Your Body Were Injured?
What Could Have Been Done To Avoid This Injury?
F|Staff Driver Signature
*
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