Accident Incident Report Form

Use this accident incident report form in case someone got hurt as a result of a crash. It can be used by fleet managers to report all the details of the incident. Use this template to help the inspector to capture all contact information and verification information of the harmed/wounded person and describe full details of the injury and the accident. S/he can also attach photo(s) as proof and document emergency services involvement (i.e. police, fire department,...), hospitalization data and witness statements. In the end, the form can be signed by all involved people.

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Accident Incident Report Form

General Information

Name of driver:

Car registration number:

Driver's license number:

Injured Person Background

Name of the injured person

His/Her Identification number

Attach photo of ID:

Gender:

Address:

Date of Birth:

Telephone Number:

Injury Details

Date and time of injury:

How exactly did the accident happen?

Describe the affected body part.

Attach a photo of the body part that was injured. Comment if necessary.

Attach photo of the surrounding of the location of the accident.

Were safety regulations used?

Witness Statements

Were there any witnesses?

Emergency Services

Did the injured went to doctor/ hospital?

Was the police called?

Sign off

Full name and signature of the injured person:

Full name and signature of the fleet manager: