Sample

Accident Investigation Form?3

Vehicular

Date of the accident _________________________

Names of the individual(s) involved ________________________

______________________________________________________

Employment status (i.e., full-time, part-time, contractor): _____________

Place of the accident (location, street address/intersection, or any other location description) ____________________________________________

What happened: ________________________________________

______________________________________________________

Vehicles or equipment involved: ___________________________

______________________________________________________

Weather conditions: _____________________________________

Was law enforcement involved? Citation(s) issued? Nature of violation?

______________________________________________________

Injuries:_______________________________________________

Name Injury? Hospitalized? W/C claim?
       
       
       
       
       


Damage to property _____________________________________

Witness Name Address Telephone