Fillable Vechicle And Equipment Accident Report Form MMA Exterior Door Proximity Reader Plan

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Vechicle And Equipment Accident Report Form MMA Exterior Door Proximity Reader Plan

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City of Bangor Vehicle or Equipment Accident Report
Department of Safety and Environmental Management
Created: 5/28/20
Revision: New 1 | Page
This form will be used by City of Bangor employees to document accidents or incidents involving city vehicles or equipment.
It is important to document the incident and report it to the Department of Safety and Environmental Management as soon as
possible in order a claim file can be created and our insurance representatives can be notified.
Driver’s Name:
Today’s Date:
mm
dd
yyyy
Driver’s License Number:
Supervisor’s Name:
City Vehicle Information:
Year
Make
Model
City Vehicle Number:
Type of Incident (
check all that apply
):
Vehicle / Equipment Damage Employee Injury
Property Damage 3
rd
Party Injury
Other:
Date of Incident:
mm
dd
yyyy
Time of Incident: AM
PM
Location of Incident (include physical address):
Description of the Incident:
What could have be done to prevent this from happening again in the future?
Included with the Report: Other Driver’s Insurance Information Police Report
Photos / Video Other: ______________________________________________________
Prepared By:
Department:
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Vechicle And Equipment Accident Report Form MMA Exterior Door Proximity Reader Plan

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Completed 11 July 2020

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