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1. General Info

Accident Date

Accident Location

Accident Description

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2. Claim Information

Claim Number

Status IncidentClosedPending

Occurrence Number

Date Reported to Client

Time Reported

Report Completed By

Name of Reporter

Reporter Phone

Record Type

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3. Load & Freight Information

Manifest Number

Airbill Number

Origin

Destination

HazMat YesNo

Freight Spillage YesNo

Service Failure? YesNoPending

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4. DOT Testing & Compliance

Citation Issued? YesNoPending

Alcohol test within 2 hours? YesNo

Offsite Medical Treatment? YesNo

Alcohol Test Completed? YesNo

Vehicle Towed Due to Damage? YesNo

Fatality? YesNo

Drug Test Completed? YesNo

Follow-Up Required? YesNo

DOT Recordable? YesNo

Steps Taken to Initiate Drug Test

If No Test, Document Reason

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5. Vehicle & Equipment Damage

Trailer Damage? YesNo

Tractor Damage? YesNo

Was Driver's Vehicle Towed? YesNo

Citation Time

Citation Offense

Describe Damage

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6. Co-Driver Information

Co-Driver Name

Was Co-Driver Transported? YesNo

Where Was Co-Driver Transported?

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7. Claimant Passengers

Other Passengers? YesNo

Passenger Injuries

Passenger Names

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8. Claimant Information

Claimant First Name

Claimant Last Name

Claimant Birth Date

Driver’s License #

License State

Email

Home Phone

Mobile Phone

Address Line 1

Address Line 2

City

State

Postal Code

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