Accident-Incident Form Accident-Incident Report Form - Employees Vehicle and Property Damage Incident Report Form I am aware and acknowledge that what I submit in this report is the truth to the best of my knowledge, and understand Windstar’s insurance company and perhaps a court of law will see what I write.* I understand Employee Name:* First Last Your phone number:*Select your Branch Location:*Please SelectCarrollCedar RapidsDes MoinesDubuqueKansas CityLas VegasLincolnOrlandoPhoenixRockfordSaint LouisSioux FallsDate of Accident:* MM slash DD slash YYYY Time of Accident:* : Hours Minutes AM PM AM/PM Vehicle Number:* Charter Number*Group Name: Location of Incident:* Street Address Address Line 2 City State / Province / Region Road Surface & Weather Conditions:* Could you have done something to prevent this accident?* Yes No Were the Police Involved?* Yes No Officer's Name and Department:* Police Report Number:* Were any Vehicles Involved Towed From The Scene?* Yes No Any fatalities?* Yes No Any Injuries?* Yes No Tell us more about the injuries that occurred:*Backing?* Yes No Tail Swing?* Yes No Were there passengers on board your vehicle?* Yes No Driver's Estimate of Damages:*Explain in detail what happened:*How could this incident have been prevented?*Describe damage to motor coach:*Are there witnesses to this accident?* Yes No Here is the link to the witness form: www.gowindstarsafety.com/witnessDid the incident involve damage to another vehicle or property?* Yes No Describe damage to other vehicle (enter none if not applicable):*Describe damage to other property (enter none if not applicable):*Other party's statement:*Other party's name:* First Last Address* Street Address Address Line 2 City State / Province / Region Other Party's Phone Number:*Insurance Carrier and Policy Number:* You are required to have pictures of the collision damage and overall scene. Do you have any pictures or documents to attach to this form? If not, you must provide these pictures to your manager.* Yes No Accident DiagramAccepted file types: jpg, jpeg, png, gif.You can download, print, complete and attach a copy of the Accident Diagram at the following link or you can get a copy from your manager to complete. Click Here for a copy of the form.Attach pictures/documents Drop files here or Select files Max. file size: 370 MB, Max. files: 10.
