HomeMy WebLinkAboutCOLVehicleAccidentReportfillableForm_10-26-18 "Ail CITY OF LANS ING VEHICLE ACCIDENT REPORT
T YOU HAVE ANACCIDENF ACCIDENF-
• DO: Date: Time: AMPM
1. Call 911 immediately if damage or injuries are involved and request
medical assistance and an officer to file a report on behalf ofthe City of Location:
Lansing.If the vehicle cannot be driven,call the Fleet Services garage
supervisor and they will arrange for a tow truck If the accident occurs
after hours,contact the on call Fleet Services supervisor,if you do not
know the number the 911 dispatch can assist, they will have the Department: Division:
number. All City vehicles involved in any accident need to report
directly to the Fleet Service garage following the accident. YOUR VEHICLE:
2 Call or radio your supervisor. Vehicle:
3. Obtain the other driver's license number, insurance it&rmation from Year Nhke Body Style
their Insurance verification ir&nnation and a description of the vehicle
from their registration card. License No. Vehicle No.
4. Give other driver your name, address and license number and show Owner:
hi Aer the State of Mchigan No Fault Insurance Certificate,which can
be found in the vehicle's glove compartment. Driver:
5. Ifsafe,take photos ofall four comers ofallvehicles,license plates,skid Diver's License:
marks,all angles of the roadway approach and persons in the vehicles
involved in the accident. Damage'
• DO NOT:
1. Admit any responsibility or make any statements about the accident to Passengers:
anyone other than:
o Police Officer OTI�ER VEHICLE:
o Your Supervisor Diver's Name:
o I-Daman Resources Department Address:
Remember you are an employee of the City oflansing and need to act
profes s ionally at all times. City&State:
City employees will complete all applicable sections ofthis form. Diver's License No. State:
Supervisor will complete this form ifthe injured is unable.Submit this Vehicle:
form to your supervis or the s ame day but no later than the next Year Nhke BodyStyle
business day after the accident. Vehicle License Plate No. State:
Supervisors/Nhnagers will complete an initial investigation,review Us Owner of Vehicle:
form for completeness,and submit to the Human Resources Address:
Depaninent within 24 hours ofthe accident for review.
City&State: Phone:
POLICE: REPORTNLA43ER
Insurance Co.
Name_Badge No. Dept. _
Policy No.
City: Who Received Ticket? Damage:
MUREDPERSONS:
W MESSES:
1.Name:
1.Name:
Address:
City&State: Phone: Address:
City&State: Phone:
Nature and Extent:
Witness Statement:
2.Name:
Address: 2.Name:
City&State: Phone: Address:
Nature and Extent: City&State: Phone:
Witness Statement:
WAS AIVBULANCE CALLED? Yes ❑ No❑
10-26-18
INSTRUCTIONS FOR FILLING OUT ACCIDENT DIAGRAM
• Indicate compass direction ondiagram
• Name streets or roads and(if any)rai roadtracks
• Indicate direction and position of each vehicle involved in the accident
• Use the letter(A)to designate Cityvehicle and(B),(C),etc.,for other vehicle(s)
ACCIDENT DIAGRAM
VEHICLE SYNBOL
03) CONVASS
(C
Where were you going to at the time ofthe accident?
ascribe what occurred:
Weather Conditions: ❑ Clear ❑ Overcast/Foggy ❑ Rain ❑ Snow ❑ Sleet ❑ Standing Water
Road Conditions:❑dry ❑wet ❑ snowy ❑icy Road Type: ❑ Freeway❑ Local ❑ Not on a Road
Were you distracted?❑Yes(Ifyes,how Acre you distracted?)❑Texting❑Typing❑Dialing❑Tallcing on Phone/Radio❑Other ❑No
Were seatbeks being worn?❑ Yes ❑No Work zone?❑Yes ❑ No
Was CDLhokler driving? ❑Yes(If yes,complete the following section)❑No Was there a fatality? ❑Yes ❑No
IfYes to any two or more of the following Questions the CDLHalder shall be sent out for Testing:
Was CDLholder ticketed? ❑Yes❑No Was any vehicle towed? ❑ Yes ❑No Was anyone taken to the hospital for their injuries? Yes ❑ No❑
Was the CDLhoklertested? Yes ❑ No❑
Signatures:Employee:By signing this document you are confining that the information provided is accurate and complete.
Employee/Driver Date
Supervisor:By signing this document,you are confirming that you have reviemd the information on this farm with the employee for thoroughness
and accuracy.Include your investigation information and any pictures taken with this report form
Supervisor Date
Supervisor Print Your Name Supervisor Contact Number
Supervisor Comments (Include info.for Accident Review: