Fillable VEHICLE ACCIDENT REPORT (City of Stephenville)

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VEHICLE ACCIDENT REPORT (City of Stephenville)

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The VEHICLE ACCIDENT REPORT (City of Stephenville) form is 3 pages long and contains:

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  • 12 check-boxes
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File type: PDF

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BROWSE CITY OF STEPHENVILLE (TX) FORMS

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VEHICLE ACCIDENT REPORT
Vehicle and Equipment Accident/Damages
This form, or an approved alternate form, must be completed for all accidents involving any City vehicle, equipment (any
item attached to a City Vehicle) or property damage caused by a City vehicle or equipment. Please report any incident
immediately and complete all related sections of this report and provide a copy of Fleet Maintenance within one (1)
business day for processing (pictures of the damages will be required at the time of incident)
Employee Injuries
Supervisors must be notified immediately by the employee and the incident should be reported to Human Resources
immediately or within one (1) business day of the incident.
Note
This form must be signed by the employee involved and the employee’s supervisor however, if signatures cannot be
obtained within one (1) business day, the form should be forwarded to Fleet Maintenance as soon as possible.
Employee Name: Home Phone #:
Home Address:
Street Number Street Name City State Zip Country
Job Title: Department:
Date of Occurrence: Time of Occurrence:
__am__pm
Date reported:
Address/Location of Occurrence:
Briefly describe accident and how or why it occurred:
Witness’ Name (include address if not a city employee):
Was drug test given?
__Yes
__No If not, state reason:
APPENDIX E
FORM 29
SECTION A – GENERAL INFORMATION
Page 240 of 254
City Vehicle #:
Was City Vehicle Damaged?
City Vehicle License #:
__Yes __No
Make and Model:
Was there a Police investigation?
Year: VIN#:
__Yes __No If yes, list investigating agency:
If yes, reportnumber:
Weather Conditions:
Description of Damage:
RoadConditions:
List all passengers in vehicle (attach additional pages, if necessary):
Name (First and Last) Age
Was other vehicle damaged?
__Yes__No
License Number: Year: Make and Model:
VehicleIdentificationNumber:
Driver’s Name:
Address:
Street Number Street Name City State Zip Country
Phone Number:
InsuranceCompany:
Policy Number:
Weather Conditions:
Insurance Agent’sPhone Number:
RoadConditions:
Description of Damage:
List all passengers in vehicle (attach additional pages, if necessary):
Name (First and Last) Age
APPENDIX E
FORM 29
SECTION B – CITY VEHICLE ACCIDENT OR DAMAGE
SECTION C – OTHER VEHICLE ACCIDENT OR DAMAGE
Page 241 of 254
SECTION D – DAMAGE TO PROPERTY
Type of Property Damaged:
Owner’s Name:
City Owned?
Yes No
Phone Number:
Address:
Street Number Street Name City State Zip Country
Description of Damage:
Name of Injured:
Address:
Street Number Street Name City State Zip Country
Phone Number:
Nature of and Part ofBody Injured:
Ambulance Needed? __Yes __No Hospital: Doctor:
Preventable – was the accident preventable?__Yes __No
Policy Violation – was a City or DepartmentalPolicy
violated?
__Yes __No
Employee Printed Name: Date:
Employee’s Signature:
Supervisor’s Printed Name: Date:
Supervisor’s Signature:
Appendix E
Form 29
SECTION E – INJURY TO MEMBER OF THE PUBLIC
SECTION F – PREVENTABLE AND/OR VIOLATION OF POLICY
COMMENTS
SIGNATURES
Page 242 of 254
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VEHICLE ACCIDENT REPORT (City of Stephenville)

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Completed 16 July 2020

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