Automobile Insurance Formal Report Writing

The written accident report must contain sufficient information, written in narrative form and in simple language, to enable re-viewing officials, or a formal board, to determine exactly what happened, why it happened, how the investigator determined what happened and why, and the basis for recommending corrective action to prevent recurrence. A recommended report format follows below.

Accident Investigation Report # ____

Section A -Background Information

1. Time & Date of Accident:

Month: _____ Day: _____ Year: _____ Time: _____

2. Weather Conditions: (Check One)

Clear_____ Rain_____ Snow _____ Fog _____ Overcast _____

3. Road Conditions:

Dry _____ Wet_____ Icy_____ Other (Explain) _____

4. Time of Day: (Check One)

Dawn_____ Day_____ Dusk_____ Night _____

5. Location: (Check One)

Company location/property_____ Other/City_____ Other/Rural_____

6. Exact Location of Accident:

Section B • Personnel Involved

7. Name (Last, First, MI) and Duties at Time of Accident

8. Social Security Number

9. Company ID #

10. Job Position/Title: __________________

11. Number of Hours on Continuous Duty Before Accident: ____

12. Number of Hours Sleep In Last 24 Hours: ____

13. This Person’s Task/Activity At the Time of the Accident:

14. Operational Category:
Identify the operational category that best describes the overall mission at the time of the accident.

15. Severity of Injury to the Person: Check the Appropriate:

_____Fatal
_____Permanent Total Disability
_____Permanent Partial Disability
_____Lost Workday Case (Days Away From Work)
_____Lost Workday Case (Restricted Work Activity)
_____First Aid Only
_____No Injury

16. Workdays Lost (Estimate): _____

17. Workdays Restricted (Estimate): _____

18. Workman’s Compensation Claim Filed: _____

19. Type/Nature of Injury/Occupational Illness:

20. Body Part Affected: _________________

21. Vehicle Restraint/Protection Device: __ Used __ Available/Not Used __ Not Available __ NA

22. Task Errors: This person’s errors which caused or contributed to the accident (Describe each mistake and the result):

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