Accident-Incident Report Form – Manager Accident-Incident Report Form - Managers 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 Enter your name (person completing this form)* First Last Driver Name* First Last Branch Location*Please selectCarrollCedar RapidsDes MoinesDubuqueKansas CityLas VegasLincolnOrlandoPhoenixRockfordSaint LouisSioux FallsVehicle Number* Location of the incident* Date of Incident* MM slash DD slash YYYY Time of Incident* : Hours Minutes AM PM AM/PM Did the driver report from the scene or as soon as they were aware of the damage?* Yes No - they should lose their bonus No - but don't take their bonus - explain why NOTE: They will lose performance bonus for 4 Quarters for failing to call from the scene.Please provide explanation as to why driver did not report from the scene:*Are you completing this form immediately after the the driver's notification?* Yes No Why was the manager's form not submitted immediately?*Short explanation of the incident*Was the accident preventable/avoidable?*YesNoWere there any fatalities?* Yes No Were there any injuries?* Yes No Unknown Were any vehicles towed from the scene?* Yes No Unknown Did our driver receive a citation?* Yes No Unknown POST-ACCIDENT Testing is required, contact the Safety Director immediately* I understand and will contact the Safety Director immediately POST-ACCIDENT Testing is required, contact the Safety Director immediately* I understand and will contact the Safety Director immediately POST-ACCIDENT Testing is required, contact the Safety Director immediately* I understand and will contact the Safety Director immediately You will need to find out ASAP if the driver received a citation or the driver must be informed that he/she must call back ASAP if they receive a citation. Post-accident testing would be required if they receive a citation and any vehicles are towed or there are injuries.
