Incident Report

Contact Info

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Our Office

5398 Market Street
Kalamazoo, MI 49048

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Open Office Hours

M-F: 8am – 5pm

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Get in Touch

P: (269) 344-3341
Fax: (269) 344-7100

All incidents must be reported WITHIN 2 HOURS

Complete this form entirely and truthfully for all personal injury or vehicle damage, property damage and freight issues. Submit to immediate supervisor upon completion. If more space is needed, please attach a separate page.

Incident Report

Employee Name:

Home Address:

City

State

Zip

Job Position

Phone Number

Cell Number

Vehicle Used (if applicable)

Trailer # (if applicable)

Load / Prophesy #:

Type of Incident Type of Incident Personal Injury Vehicle Damage Property Damage Freight Issues

Date of Incident

Time of Incident

Location, City, and State of incident

Time Shift Began

Job being performed when incident occurred

Describe how incident happened

When was incident reported?

Name(s) of Witness (s)

Was the employee injured? Was the employee injured? Yes No

If yes, what part of body?

Describe the injury in detail

Was first aid given? Was first aid given? Yes No

If yes, by whom?

Any medical attention (other than first aid)? If yes = OSHA Recordable (F100 Form)

Name of doctor and/or hospital

Doctor contact information (phone, city, state)

Any other persons injured? Any other persons injured? Yes No

If yes, what part of body?

Describe the injury in detail

Was first aid given? Was first aid given? Yes No

If yes, by whom?

Any medical attention (other than first aid)? Any medical attention (other than first aid)? Yes No

Name of doctor and/or hospital

Doctor contact information (phone, city, state)

If employee was involved in a vehicle accident, please complete the following. If employee was involved in a vehicle accident, please complete the following. Yes, a vehicle was involved in this incident.

Police called? Police called? Yes No

Any damage the vehicle being operated? (If yes, TAKE PICTURES)

Describe damage

Did our vehicle need to be towed? Did our vehicle need to be towed? Yes No

If yes, towing company name

Describe damage

Any other vehicles involved? Any other vehicles involved? Yes No

Any damage to other vehicle(s)? If yes, TAKE PICTURES Any damage to other vehicle(s)? If yes, TAKE PICTURES Yes No

Did other vehicle need to be towed? Did other vehicle need to be towed? Yes No

If yes, towing company name

Did employee exchange insurance information with other driver? Did employee exchange insurance information with other driver? Yes No

Did employee complete the accident report kit? (Fax accident report to 269-344-7100) Did employee complete the accident report kit? (Fax accident report to 269-344-7100) Yes No

Any damage to surrounding property? (If yes, TAKE PICTURES) Any damage to surrounding property? (If yes, TAKE PICTURES) Yes No

If yes, describe object damage

Freight description

BOL or Shipping Document Number(s)

Shipper

Receiver

Any missing freight? Any missing freight? Yes No

If yes, number of missing items

Any damage to freight? (If yes, TAKE PICTURES) Any damage to freight? (If yes, TAKE PICTURES) Yes No

Describe damage / shortage / overage

By completing this form and checking this box, you are verifying the accuracy and completeness of this form. By completing this form and checking this box, you are verifying the accuracy and completeness of this form. I verify the accuracy and completeness of this form.