auto crash/incident checklist

Auto Crash/Incident Checklist Employee Name: _ _ _ _

Date of Incident: Location #: _ In the event of an auto crash or wheelchair/scoter incident contact Zoe Robinette: 415-806-9348 or email [email protected] immediately upon notice. Complete this Incident Packet at email to [email protected] and Monique Lemus at [email protected]

¨ Initiate Emergency Procedures (Dial 911 if needed)

¨ Follow Injured Employee Protocol if needed

¨ Auto Insurance Document

¨ Auto Crash Incident Report

¨ Driver’s Statement

¨ Root Cause Analyst and Prevention Report

¨ Photos of Crash Site

¨ Witness Statement

¨ Waiver of Medical Treatment

¨ Supplemental Passenger List

¨ Goggle Maps of incident Site

¨ Post Incident Decision Guide

¨ Copy of Temco Vehicle Identification Card

¨ Copy of Other Vehicle Registration Identification Card

¨ Video of incident if available

LOCATION MANAGER/SUPERVISOR – Sign and submit this form with documents via E-mail to: [email protected] -Monique Lemus at [email protected]

_ _ Completed by (print name) Phone # SIGNATURE DATE

Auto Crash/Incident Checklist ¨ Non-Collision Incident Report

¨ Auto Insurance Document

¨ Root Cause Analyst and Prevention Report

¨ Witness Statement

¨ Waiver of Medical Treatment

¨ Supplemental Passenger List

¨ Goggle Maps of incident Site

¨ Copy of Temco Vehicle Identification Card

¨ Video of incident if available

LOCATION MANAGER/SUPERVISOR – Sign and submit this form with documents via E-mail to: [email protected] - Monique Lemus at [email protected]

_ _ Completed by (print name) Phone # SIGNATURE DATERev 7/1/19

Driver’sStatementofIncidentDocument

Driver’sSignature _

Date _

WITNESSFORM

NameofWitness JobTitle/Employer AddressofEmployer(ifotherthanBNL)

TelephoneNumber(s) E-MailAddress(es) HomeAddressWork:Cellular:Home:

IncidentDate Timethewitnessarrivedatthescene

Timethewitnessleftthescene

1. Otherpersonsthewitnesssawatthescenewhilethewitnesswasthere?

2. Describewherethewitnesswaslocatedinrelationtotheincidentscene.

3. Pleasedescribewhatthewitnesssaw,heard,feltand/orsmelledduringtheincident:

4. Pleasefullydescribetheworkandconditionsinprogressleadinguptotheevent.

5. Didthewitnessnoteanythingunusualpriortoorduringtheincident?Ifyes,pleasedescribewhatthewitnessnotedandwhythewitnessthinksitwasunusual.

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6. Whatwasthewitness’sroleintheincidentsequence?

7. Whatconditionsinfluencedtheincident?(Weather,timeofday,etc.).

8. Howdidpeopleinfluencetheincident?(Actions,emergencyresponse,etc.)

9. Additionalcomments/observations:

PrintWitnessName: Date:

WitnessSignature: Time:

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INCIDENT REPORT

Please Provide the Following:

Full Driver Name:

Date of Incident:

Driver contact number:

Driver email address:

Passengers? Yes or No:

Names of Passengers:

Year, Make, Model of vehicle:

Vehicle Identification Number (VIN):

Police Report? YES or NO:

Police Report Number and Precinct: Video of

Accident? YES or NO Vehicle Damage:

Vehicle Domicile Location:

Other Driver Information

Name:

DL Number:

Address:

Phone Number:

Vehicle Year, Male and Model:

Vehicle Damage:

Insurance Company Name and Number: Accident

Details:

Driver’s Auto Crash Incident Report Form

AM PM

N S E W

N S E W

Date of Incident Day of Week (circle one)

Mon Tue Wed Thurs Fri Sat Sun Time of Accident

/ Location - Street or Highway & City

On what street were you driving? Direction (circle one) Speed (approximate)

On what street was other vehicle driving? Direction (circle one) Speed (approximate)

Police Report? If yes, name of reporting officer Agency Citation/Report # Yes No

Witness #1 Name (first and last) Telephone No. Email Address ( )

Witness #2 Name (first and last) Telephone No. Email Address ( )

Description of Auto Crash (include weather and road conditions Use driver’s statement document if more room is needed):

IN THE EVENT OF AN AUTO CRASH INCIDENT Driver – Complete all items to the best of your ability, sign and date page 3, and immediately give it to your supervisor. Supervisor – Email this to [email protected] and Monique Lemus at [email protected]

Driver/Vehicle Information Name of Driver (first and last) Driver License No. State

Driver’s Address – Street City State Zip Telephone No.

( ) Name of Employer ANI/NIAC Policy Number

Employer Contact Name Contact Email Address

Employer Address – Street City State Zip Telephone No.

( ) Vehicle Number Complete V.I.N #

Make of Vehicle Model Year License Plate # Driver Injury Yes/No

Damage to Vehicle:

Auto Crash Incident Information

Driver’s Auto Crash Incident Report Form (Usethebackofthissheet ifadditionalspaceisneeded;pleaseusethediagramsonpage3todrawtheaccident)

Passenger(s) in Your Vehicle (Attached statement from each passenger additional pages if needed)

Name (first and last) Telephone No.

( ) Email Address Injuries?

Yes No

Name Telephone No.


Yes No

Name Telephone No.


Yes No

Ambulance called to scene? Yes No

Name of doctor or hospital

Other Vehicle Involved Name of Driver (first and last) Driver License No. State

Address - Street City/State/Zip Telephone No.

( ) Email Address

Name of Vehicle Owner (if different than above) Telephone No.

( ) Email Address

Name of Insurance Company Policy # Telephone No.

( ) Year/Make of Vehicle Body Type License Plate No.

Damage to Vehicle:

Passenger’s Name (first and last) Telephone No.


Yes No

Passenger’s Name (first and last) Telephone No.


Yes No

Other Vehicle Involved (if any)

Name of Driver (first and last) Driver License No. State

Address - Street City/State/Zip Telephone No.

( ) Email Address

Name of Vehicle Owner (if different than above) Telephone No.

( ) Email Address

Name of Insurance Company Policy # Telephone No.

( )


Company 1

Vehicle 2

Year/Make of Vehicle Body Type License Plate No. State

Damage to Vehicle

Passenger’s Name (First and Last) Telephone Number

( )

Email Address Injuries? Yes No

Passenger’s Name (First and Last) Telephone Number

( )

Email Address Injuries? Yes No

On the diagrams below, please draw the incident scene. Legend - N E S W (Be sure to include any stop signs or traffic signals.)

▌ ▐ ▌ ▐ ▌ ▐ ▌ ▐

Vehicle 3

North

▌ ▌ ▌ ▌ ▌ ▌ ▌ ▌ ▌ ▌


On the overhead diagrams below, please indicate the location of damage to your vehicle, if any.

back ------------ Bus/Van ------------ front back -------------- AUTO ------------- front

SIGNATURE OF DRIVER DATE

WAIVER OF MEDICAL ASSISTANCE

I hereby decline offered medical assistance and agree to accept full responsibility for that decision on my own behalf and on behalf of my personal representatives.

I further agree to release and hold harmless PCI, its employees, officers, directors and agents from any liability whatsoever, regardless of negligence or cause, arising in any way from my declination of medical assistance.

I have read and understood the foregoing and freely sign it on

this date of , 2020

Signature:

Please Print the Following Information

My Name:

My Address:

My City & Zip Code:

My Phone #:

Supplemental Passenger List (Attach to the Incident Report Form)

Report #

1) Passenger Name:

Address :

Phone Number :

2) Passenger Name:

Address :

Phone Number :

3) Passenger Name:

Address :

Phone Number :

4) Passenger Name:

Address :

Phone Number :

5) Passenger Name:

Address :

Phone Number :

6) Passenger Name:

Address :

Phone Number : (Use additional sheets as necessary)

auto crash/incident checklist

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