Vehicle Accident Or Damage Report Form PDF Details

Our printable vehicle accident report form includes personal and car information of the involved parties, specific incident details, and a diagram. It also records the extent of property damage, injuries, witness accounts, and investigative notes from police, if applicable.

Filling out this car accident report form is essential following any incidents involving county vehicles. This way, you document all necessary details for the insurance company, as well as legal and administrative processes. This form must be completed under various conditions:

- Any traffic accident with a county vehicle, irrespective of damage or injuries.

- Incidents resulting in damage to county property or other personal assets.

- Situations where drivers, passengers, or bystanders sustain injuries.

This auto incident report form should be submitted within 24 hours of the incident. Delays or inaccuracies in submission can complicate claims handling or lead to disciplinary actions against drivers involved.

QuestionAnswer
Form Name Vehicle Accident Or Damage Report Form
Form Length 2 pages
Fillable? Yes
Fillable fields 124
Avg. time to fill out 15 min
Other names vehicle accident investigation report form, car accident report sample PDF, employee vehicle accident report form

Form Preview Example

VEHICLE ACCIDENT OR DAMAGE REPORT

IMPORTANT This form must be completed for all damage or injury involving county vehicles within 24 hours. Enter the information into INSTRUCTIONS STARSWeb. Place the STARS claim number on the top right hand corner of page two. FAX the entire report to

Risk Management at (410) 222-7640. Forward the original form to Risk Management at MS 9303.

SECTION 1 COUNTY VEHICLE #1

SECTION 2 OTHER VEHICLE #2

SECTION 3

SECTION 4 DETAILED DESCRIPTION OF ACCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE PRINT OR TYPE

 

 

 

 

 

 

 

Anne Arundel County, MD

EMPLOYEE’S FIRST NAME MIDDLE LAST NAME

 

 

JOB TITLE

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

HOME PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE’S STREET ADDRESS

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

STATE

 

 

 

ZIP

 

 

WORK PHONE

 

 

EXT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPT/SUB-DEPT/SECTION IDENTIFICATION

 

 

 

 

 

 

 

 

 

DEPT CODE

 

 

 

COUNTY VEHICLE NUMBER

 

TAG NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER LICENSE NUMBER

 

 

 

 

 

 

CLASS

 

EXPIRES

 

 

 

 

STATE

 

 

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IS VEHICLE DRIVABLE?

 

 

DRIVEN FROM SCENE?

 

 

INVESTIGATED BY:

 

 

 

 

 

 

 

REPORT NUMBER

Yes

No

 

 

Yes

 

No

 

 

County

 

 

State or

 

City Police

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE MAKE

 

 

 

 

VEHICLE MODEL

 

 

 

 

 

 

 

 

 

 

 

YEAR

 

 

WERE SEATBELTS BEING WORN?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION OF VEHICLE DAMAGE (Extent and Location)

 

 

 

 

 

 

WAS DRIVER INJURED?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ON DUTY?

 

 

 

 

 

 

 

RESPONDING TO EMERGENCY?

 

 

 

 

 

 

 

 

WERE LIGHTS & SIREN ACTIVATED?

 

 

 

 

Yes

No

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME(S) OF PASSENGERS

 

PHONE

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

INJURIES

 

 

 

 

AGE

PASSENGERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE MAKE

 

 

YEAR

 

 

TAG NUMBER

 

IS VEHICLE DRIVABLE?

DRIVEN FROM SCENE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF DRIVER

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

STATE

ZIP

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF OWNER

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

STATE

ZIP

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION OF VEHICLE DAMAGE (Extent and Location)

 

 

 

 

 

 

 

 

 

WAS DRIVER INJURED?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME(S) OF PASSENGERS

 

PHONE

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

INJURIES

 

 

 

 

AGE

PASSENGERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE COMPANY NAME

 

 

 

 

AGENT’S NAME

 

 

 

 

 

AGENT’S PHONE NUMBER

INSURANCE POLICY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 OR MORE VEHICLES

 

Complete Section 2 on additional Vehicle Accident or Damage Report Forms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF OWNER

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

CITY

 

 

 

STATE

 

ZIP

 

PHONE NUMBER

DAMAGE TO PROPERTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER THAN AUTO

 

KIND OF PROPERTY

 

 

 

 

EXTENT AND TYPE OF DAMAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

CITY

 

 

 

STATE

 

ZIP

 

PHONE NUMBER

INDEPENDENT WITNESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

CITY

 

 

 

STATE

 

ZIP

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCIDENT DATE

HOUR

 

WEATHER

 

 

 

 

 

 

LOCATION OF ACCIDENT - STREET OR HIGHWAY

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCIDENT

Show & Label:

 

Roads, Traffic Units,

 

North:

 

 

DESCRIBE ACCIDENT briefly: identify units by numbers. Also identify other

 

 

 

 

the Travel Direction

 

Indicate

DIAGRAM

 

 

 

 

 

OBJECTS DAMAGED & NATURE OF DAMAGE (Property other than vehicles)

 

 

 

 

 

 

 

 

 

 

 

 

 

N

DATE OF THIS REPORT

EMPLOYEE SIGNATURE

4/5/06

Page 1

VEHICLE ACCIDENT OR DAMAGE REPORT (PAGE 2)

STARS CLAIM NUMBER

MUST BE COMPLETED BY SUPERVISOR

EMPLOYEE WORK STATUS

CAUSES

CORRECTIVE ACTION

SUPERVISOR COMMENTS

SIGNATURE

DID THE EMPLOYEE SEEK MEDICAL TREATMENT?

Yes

No

 

 

 

 

If Yes, provide Name, Address, Phone:

 

 

 

 

 

 

 

 

 

 

 

WAS WORKERS’ COMPENSATION INCIDENT REPORT FORM COMPLETED?

Yes

No

 

 

 

 

 

 

 

 

HOURS OF CONTINUOUS DUTY FOR EMPLOYEE DRIVER?

 

 

WAS THE EMPLOYEE FOLLOWING COUNTY PROCEDURE(S)?

Yes

No

 

 

 

 

 

 

 

YEARS OF EXPERIENCE DOING THIS JOB

 

 

 

 

 

 

 

 

 

 

 

 

 

FACTORS CONTRIBUTING TO THE INCIDENT (Check all that apply)

INATTENTION

 

ATTITUDE

PHYSICAL IMPAIRMENT

 

 

UNSAFE EQUIPMENT

EQUIPMENT FAILURE

FATIGUE

LACK OF TRAINING

 

 

 

IMPROPER MAINTENANCE

DRIVING TOO FAST FOR CONDITIONS

INEXPERIENCE

LIGHTING (CHECK THE ONE THAT APPLIES)

 

 

OTHER, EXPLAIN

 

DAYLIGHT

DUSK/DAWN

NIGHT

SHADOWS

SUN/GLARE

 

 

 

 

 

 

HAS EMPLOYEE RECEIVED PREVIOUS NOTICES OR WARNINGS ABOUT THEIR UNSAFE ACTS OR CONDITIONS?

Yes

No

 

 

 

If Yes, when

Oral or Written

 

 

 

 

 

 

 

 

 

 

 

 

WHAT ACTION HAS BEEN TAKEN TO CORRECT OR ELIMINATE THE UNSAFE ACT OR CONDITION (Check all that apply)

 

 

 

 

DISCUSSED INCIDENT WITH EMPLOYEE

 

DISCUSSED INCIDENT WITH OTHERS THAT DO THE SAME WORK

EMPLOYEE RETRAINED

 

PROVIDED TRAINING/RETRAINING TO ALL EMPLOYEES

 

REPAIRED EQUIPMENT OR CONDITION

 

VERIFIED SAFETY EQUIPMENT IS OPERABLE, AVAILABLE

 

INITIATED DAILY SAFETY LOGS

 

INSTITUTED INSPECTION PROGRAM

 

 

 

REVIEWED POLICY & PROCEDURE WITH EMPLOYEE

OTHER, PLEASE EXPLAIN

 

 

 

 

REQUESTED MODIFICATION OF EQUIPMENT

 

 

 

 

 

 

 

RECOMMENDED CHANGES TO POLICY & PROCEDURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREVENTABLE?

Yes, How?

 

No, Why,?

 

 

 

 

 

ADDITIONAL COMMENTS

 

SIGNATURE OF SUPERVISOR & PRINTED NAME

DATE

DATE YOU WERE NOTIFIED OF INCIDENT

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBER

SECTION IDENTIFICATION

 

 

 

 

 

 

 

BUSINESS UNIT/COST CENTER NUMBER

MAIL STOP NUMBER

 

 

 

 

 

 

FOR OFFICE USE

PERSON ENTERING DATA INTO STARS

PHONE NUMBER

DATE

How to Edit Vehicle Accident Or Damage Report Form Online for Free

A vehicle accident report template is essential for all insurance company claims, legal matters, and internal reviews. Below is a step-by-step guide on how to complete this form correctly.

1. Basic Info and Vehicle Identification Number

Start by filling out the basic information for the employees and vehicle. Include the employee's name, driver's license, job title, department, contact details, vehicle make, model, year, and tag number. This data sets the context for the report.

Vehicle Accident Or Damage Report Form writing process described (portion 1)

2. Document the Accident Details

Record details about the accident, such as the date when the crash occurred, time, and location. Note the weather conditions and note whether the vehicle was driven from the scene. Include a diagram of the accident layout to provide a clear visual understanding of the incident.

3. Describe Vehicle Damage and Injuries

Detail the extent and location of the vehicle's damage. If there were any injuries to the driver or passengers, describe these as well. Confirm whether seatbelts were worn and if the vehicle was drivable post-accident.

AGENTS NAME, Complete Section on additional, and OR MORE VEHICLES in Vehicle Accident Or Damage Report Form

4. Witness Information for Insurance Company

If there were any witnesses to the crash or incident, record their names, phone numbers, and addresses. Witness accounts can be crucial for insurance and legal purposes.

 

The best way to fill out Vehicle Accident Or Damage Report Form part 3

5. Report on Law Enforcement Involvement

Indicate whether the accident was investigated by local, county, or state police and include any relevant report numbers. This information may be necessary for official records and proceedings of the traffic accident.

Step no. 4 for filling out Vehicle Accident Or Damage Report Form

6. Include Additional Information

Fill out any additional relevant sections such as damage to other property, involvement of other vehicles, and any post-accident measures, like the person seeking medical treatment or the status of a workers' compensation claim.

The right way to fill out Vehicle Accident Or Damage Report Form part 5

7. Review and Sign the Vehicle Accident Report Form

Ensure all information is accurate, complete, and comprehensive. The employee and a supervisor must sign the form, verifying the correctness of the information. Submit the completed form as directed, typically within 24 hours of the incident, to ensure timely processing.

Vehicle Accident Or Damage Report Form isn’t the one you’re looking for?

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