Employer Vehicle Accident Report
Employer & Employee Information
Employer Name
Employee Name
Employee ID/Number
Department
Contact Information
Vehicle Information
Vehicle Make & Model
Vehicle License Plate
Vehicle Identification Number (VIN)
Accident Details
Date of Accident
Time of Accident
Accident Location
Description of Accident
Other Parties Involved
Name(s) and Contact Information
Vehicle Details (if any)
Injuries and Damages
Were there any injuries?
Describe Injuries (if any)
Description of Vehicle Damage
Police & Insurance
Was Police Notified?
Police Report Number
Officer Name/Badge #
Insurance Company Notified?
Insurance Claim Number
Additional Comments
Report Completed By
Date
Signature