Vehicle Accident Or Damage Report Form PDF Details

Are you dealing with the aftermath of vehicle damage or an accident? Have you ever wondered why form-filling was necessary in cases like these, and what information needs to be included? In this blog post we discuss how a detailed Vehicle Accident Or Damage Report Form can help both parties involved understand the scope of what occurred and document it for future reference. We also provide insight into which information should be gathered, formatted, and shared within this form. Let's dive in!

QuestionAnswer
Form NameVehicle Accident Or Damage Report Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names13 018 Appendix I vehicle accident investigation 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

Vehicle Accident Or Damage Report Form can be filled in online with ease. Simply open FormsPal PDF tool to get the job done in a timely fashion. Our tool is constantly evolving to provide the best user experience achievable, and that's because of our commitment to continual development and listening closely to user feedback. For anyone who is seeking to get going, this is what it will take:

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Step 2: Using this state-of-the-art PDF editor, you'll be able to do more than merely fill in blank fields. Try each of the functions and make your docs look faultless with custom textual content incorporated, or tweak the original input to perfection - all that supported by an ability to add almost any photos and sign it off.

It really is simple to fill out the document using this practical guide! Here's what you must do:

1. Fill out the Vehicle Accident Or Damage Report Form with a selection of essential blank fields. Collect all of the required information and make sure nothing is omitted!

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

2. Right after this section is done, proceed to type in the relevant details in these - OTHER VEHICLE, INSURANCE COMPANY NAME, AGENTS NAME, AGENTS PHONE NUMBER, INSURANCE POLICY NUMBER, OR MORE VEHICLES, Complete Section on additional, NAME OF OWNER, STREET ADDRESS, CITY, STATE ZIP, PHONE NUMBER, DAMAGE TO PROPERTY, OTHER THAN AUTO, and KIND OF PROPERTY.

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

People often get some points incorrect while filling in AGENTS NAME in this area. Remember to read twice everything you type in here.

3. The next step will be simple - fill out all of the blanks in DATE OF THIS REPORT, EMPLOYEE SIGNATURE, and Page to conclude the current step.

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

4. To go ahead, the following form section will require typing in a couple of blank fields. Included in these are VEHICLE ACCIDENT OR DAMAGE REPORT, STARS CLAIM NUMBER, S U T A T S K R O W E E Y O L P M E, DID THE EMPLOYEE SEEK MEDICAL, WAS WORKERS COMPENSATION INCIDENT, HOURS OF CONTINUOUS DUTY FOR, WAS THE EMPLOYEE FOLLOWING COUNTY, YEARS OF EXPERIENCE DOING THIS JOB, FACTORS CONTRIBUTING TO THE, INATTENTION, EQUIPMENT FAILURE, ATTITUDE, FATIGUE, PHYSICAL IMPAIRMENT, and UNSAFE EQUIPMENT, which you'll find key to moving forward with this document.

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

5. The pdf has to be wrapped up within this segment. Here there can be found an extensive listing of blanks that have to be completed with correct information in order for your document usage to be complete: R O S V R E P U S Y B D E T E L P, DISCUSSED INCIDENT WITH EMPLOYEE, DISCUSSED INCIDENT WITH OTHERS, EMPLOYEE RETRAINED, PROVIDED TRAININGRETRAINING TO ALL, REPAIRED EQUIPMENT OR CONDITION, VERIFIED SAFETY EQUIPMENT IS, INITIATED DAILY SAFETY LOGS, INSTITUTED INSPECTION PROGRAM, REVIEWED POLICY PROCEDURE WITH, OTHER PLEASE EXPLAIN, REQUESTED MODIFICATION OF EQUIPMENT, RECOMMENDED CHANGES TO POLICY, PREVENTABLE Yes How, and No Why.

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

Step 3: When you have looked over the information in the fields, click "Done" to complete your form at FormsPal. Join us right now and easily obtain Vehicle Accident Or Damage Report Form, available for download. All alterations you make are preserved , helping you to change the pdf later when required. At FormsPal.com, we strive to make sure all your details are kept protected.

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