Full Name: [DRIVER NAME] Driver’s License No.: [DL NO.]

Address: [DRIVER ADDRESS] Phone: [PHONE]

Company / Employer: [COMPANY / EMPLOYER NAME] Employee No.: [EMPLOYEE NO.]

Truck Fleet / Registration No.: [TRUCK FLEET (IF ANY) AND REG. NO.]

Trailer Fleet / Registration No.: [TRAILER FLEET (IF ANY) AND REG. NO.]

Signature:                                                               Date: [MM/DD/YYYY]

INCIDENT DETAILS

Date of Incident: [MM/DD/YYYY] Time: [TIME] ☐ AM ☐ PM

Incident Type: ☐ Collision ☐ Injury ☐ Equipment Failure ☐ Cargo Spill
☐ Interaction / Conflict ☐ Customer Complaint ☐ Other: [OTHER]

Location: [INCIDENT LOCATION]

Describe the Incident: [DESCRIBE INCIDENT]

Truck Towed? ☐ Yes ☐ No | If yes, specify towing company: [COMPANY NAME]

OTHER PARTIES INVOLVED

1. Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
   Address: [ADDRESS]  
   Identification: ☐ Driver’s License No.: [DL NO.] ☐ Other.: [OTHER NO.]
2. Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
   Address: [ADDRESS]  
   Identification: ☐ Driver’s License No.: [DL NO.] ☐ Other: [OTHER NO.]
3. Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
   Address: [ADDRESS]  
   Identification: ☐ Driver’s License No.: [DL NO.] ☐ Other: [OTHER NO.]

INJURIES / DAMAGE

Was anyone injured? ☐ Yes ☐ No
If yes, describe the injuries: [DESCRIBE INJURIES]

Was there damage to any equipment/property? ☐ Yes ☐ No
If yes, describe the damage: [DESCRIBE DAMAGE]

WITNESSES

Were there witnesses to the incident? ☐ Yes ☐ No
If yes, enter the witnesses’ names and contact info:

1. Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
2. Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
3. Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]

POLICE / MEDICAL SERVICES

Police Notified? ☐ Yes ☐ No | If yes, was a report filed? ☐ Yes ☐ No

Was medical treatment provided? ☐ Yes ☐ No ☐ Refused
If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: [SPECIFY]