VEHICLE INCIDENT REPORT FORM

VEHICLE INCIDENT REPORT FORM

**Call the Safety & Fleet Manager IMMEDIATELY**

**Please complete all fields applicable to your incident**

**Incomplete forms will be returned for more detail**

Associate Name*

Team*

Select or enter value

Manager/Lead*

Select or enter value

SMG Vehicle VIN*

Incident Date*

Incident Time*

Weather at Time of Incident*

# Vehicles Involved*

# Injured*

County/Township of Incident*

Nearest City/Town and State*

Street, Road or Crossroads Nearest to Incident*

Were Other Parties Involved or Property Damaged?*

Property damage refers to property not owned by SMG

Yes

Were Police Contacted?*

Yes

Were Police on the Scene?*

Yes

Why Wouldn't Police Respond to Scene?*

Police Officer Name, Badge #, Dept Name*

Police Report #*

Description of Incident and Scene; SMG is V1*

Other drivers are V2, V3, etc Pictures of damages to SMG vehicle, other vehicles or property must be attached

Incident Pictures*

Involved parties driver's licenses, insurance cards Pictures of damages to SMG vehicle, other vehicle or property Pictures of scene

Drag and drop files here or

Other Involved Drivers' Information

Please obtain name, address, phone, driver's license and insurance information for ALL parties involved. If more than two parties are involved, please send a separate attachment to your supervisor.

Driver 1 Name, Address, and Phone Number

Driver 1 License Number and State

Picture of DL may be uploaded instead of text entry

Driver 1 Insurance Carrier Name and Phone #

If no insurance, enter uninsured Picture of insurance card may be uploaded instead of text entry

Driver 1 Vehicle Make, Model, Plate #, Plate State

Is Driver 1 the Owner of the Involved Vehicle?

Yes

Driver 1 Vehicle Owner Name, Address, Phone #

If Driver 1 is Owner of Vehicle 1, enter NA.

Driver 2 Name, Address, and Phone Number

Driver 2 License Number and State

Picture of DL may be uploaded instead of text entry

Driver 2 Insurance Carrier Name and Phone #

Picture of insurance card may be uploaded instead of text entry

Driver 2 Vehicle Make, Model, Plate #, Plate State

Is Driver 2 the Owner of the Involved Vehicle?

Yes

Driver 2 Vehicle Owner Name, Address, Phone #

If Driver 2 is Owner of Vehicle 2, enter NA.

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