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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
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
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
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 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
Incident Report / Near Miss
Date of Incident
Date Format: MM slash DD slash YYYY
Time of Incident

: HH

MM
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 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
Injury Report
Date of Injury
Date Format: MM slash DD slash YYYY
Time of Injury

: HH

MM
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 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 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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Goodyear, AZ 85338
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