SHAAN
Accident Report

DRIVER'S ACCIDENT REPORT KIT

Steps to follow in the event of an accident

1. Remain at the scene. Turn on four-way flashers, set out flares or reflectors.
2. Check for immediate danger, such as fuel spills.
3. Ensure that seriously injured parties are cared for. If necessary, Call an ambulance.
4. Notify the Police.
5. Notify your employer, and have your employer notify your Insurance Company Immediately.
6. Have witness cards (included in the centre of this kit) filled out by anyone who saw the accident.
7. Complete this report at the scene of the accident.
8. If possible, take pictures of the scene. Do not take photographs of victims.
9. Do not discuss the accident with anyone except the police or your Insurance representative.
10. Submit this report to your supervisor and Safety Personnel as soon as possible. Do not distribute or copy this report to others.

This report is to be completed at the scene of the accident by the driver. This report is for internal use only and not submitted to the Insurance Company.


Driver Information

Owner Information

Vehicle Information

Describe the unit or tractor that you were driving:

Describe the type of trailer(s) that you were pulling:

Cargo Loss Information

Was the cargo damaged?

Estimated value of the damage:

Describe the damage to the cargo:

Accident Information

Street name(s) where the accident occurred:

s
Were your headlights on when the accident occurred?
Were warning signals given prior to the accident occurring 7

Road/Weather Conditions


Describe the road conditions by circling one or more of the following:

Describe the traffic controls at the intersection by circling one or more of the following:

Describe the traffic conditions just prior to the accident by circling one or more of the following:

Describe the weather conditions just prior to the accident by circling one or more of the following:

Describe the visibility just prior to the accident by circling one or more of the following:

Describe how the Accident Occurred

Hidden

Please describe the movements or actions of the other vehicles involved in the accident by checking the appropriate box(es).

Action or movement of the other vehicles
Driving straight ahead
Turning right
Turning left
Making a U Turn
Lost control
Stopped or parked
Backing up
Jack-knifed trailer
Passing right side
Passing left side
Weaving
Skidding
On the wrong side
Other (describe)

Please describe all the details of the accident

(Additional space is provided after this page if required):

Third-Party/Other Vehicle Information – Vehicle 1

Driver's name:
Driver‘s address:
MM slash DD slash YYYY
Owner/employer’s address:
Was anyone in the vehicle injured?
.

Third-Party/Other Vehicle Information - Vehicle 2

Driver’s name:
Driver's address:
MM slash DD slash YYYY
Owner/employer’s name:
Owner/employer’s address:
Was anyone in the vehicle injured?
Was anyone in the vehicle injured?

Police Information

Were the police present at the accident?
Was anyone arrested?

Witness information (to be collected by the driver)

License plate number of vehicles at the scene of the accident - but not involved in the accident - who could act as witnesses:

Witness Card # 1

If you were a witness to this accident, please complete this card and return it to the driver.

Address

Thank you for your assistance

Witness Card # 2

If you were a witness to this accident, please complete this card and return it to the driver.

Address

Thank you for your assistance

Witness Card # 3

If you were a witness to this accident, please complete this card and return it to the driver.

Address

Thank you for your assistance

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