PRELIMINARY REPORT OF ACCIDENT OR LOSS
(To Be Completed When Driver Calls to Report Accident or Loss)
Date of Accident Time M A.M. M P.M. Day of Week
TOTAL NUMBER OF VEHICLES INVOLVED IN ACCIDENT? COMPANY OTHERS
Company Driver Truck or Tractor No. Trailer No.(s)
Have YOU been cited for a moving violation? M Yes M No
Can you be reached by phone, if necessary to call back? Phone No. ( ) City State
Accident Within In
City, Town or (City, Town, Village) (County) (State)
Village Limits On (Street) At or Near (Cross Street)
Accident Occurred on Near In
(Route Number and Road Name) (Town) (County)
Accident
Outside At Total Number of Lanes Were Lanes
City, Town or (Name intersection or state distance and (Both Directions) Marked? M Yes M No
Village Limits direction from nearest community, highway
junction, crossroad, milepost)
E
Were Opposing Lanes Separated by a Curb or Median? M Yes M No
TRAFFIC CONTROL AT SCENE
L
1. Signal Light M 3. Police Officer M 5. RR Lights/Gates M 7. Work Zone M 9. No Control M
2. Stop Sign M 4. Warning Sign M 6. RR Crossbuck M 8. Other Control M
Weather Condition
P
Condition of Road
Description of Accident:
Cause of
Accident
or Loss
Driver
of
Other
Vehicle
Name
Address
A M
Operator’s License No.
(Street or R.D.)
(No.)
(City & State)
(State)
Make of Vehicle
Model
Registration
(No.) (State)
S
Casualties? (indicate number) Yes No
Fatalities Injuries Have you properly set emergency warning devices? M M
Company Employee Have you secured witnesses - names & addresses? M M
Occupants other vehicles Did accident involve fire or explosion? M M
Pedestrians Can your unit proceed safely under own power? M M
Have you called Police? M Yes M No Did accident damage cause ANY vehicle to be towed? M M
Have you called for medical assistance? M Yes M No REMARKS
Where have injured persons been taken?
Hospital City/State
Was unit transporting hazardous materials? M Hazardous substances M Hazardous waste M Marine pollutants
Give name(s) and class(es) of hazardous materials
Was unit transporting oil subject to oil spill response plan?
Were there any leaks or spills of the above materials?
Is there any fuel leakage from your unit?
Notes on instructions to Company Employee: (Use other side of this form for additional information)
Person Notified Time M A.M. M P.M.
Date Signature
Copyright 2016 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 3195 (Rev. 1/16)
