QHSE Management System

Level 4
QHSEF NO.
TITLE:

VEHICLE ACCIDENT REPORT

IPS Location / Facility:
Address & Phone Number
Date of Accident

Time:

Name of Driver:

Address & Phone Number

Age:

Drivers License #

Relation to IPS:

Was car used with Owners Permission:

Make:

Year:

Model:

Location of Accident

Unit Serial #

License # / Year / State

For what purpose was auto being used at time of accident:

Where may auto be seen:
Police Investigation:

Estimated cost of repair:

Name & Address of Police Station:

Persons arrested/Driver at fault/not at

fault

Type of arrest citation:

Name of Driver
Damage to
Property of Others
(Use additional
sheet if necessary)

Address

Phone Res:
Wk:

Drivers License #:

Birth date:

Name of Insurance company / Policy Report #

List damage, if auto: Make / Year/ License #
Cost of Repair

Persons Injured:

Name of Injured
Phone

Address

IPS
Car

Other Car

Occupants of Insured Car

Address

Phone Hm
Wk

Issued by

QHSE Manager

Revision No.

Authorised by

Chairman & CEO

Date

01st Jan, 10

Page 1 of 2

QHSE Management System

Level 4
QHSEF NO.
TITLE:

Names and
Addresses of
Uninjured
Occupants and
Witnesses

Occupants of Other Car

Address

Other Witnesses

Address

Phone Hm
Wk

Phone Hm
Wk

Description of
Accident

Complete the following diagram showing direction & position of automobile or property
involved. Designating clearly point of contact. Indicate point of Compass N. E. S. W.
1

Instructions: Give Street Names, directions and Locations of Objects Involved. Car No1 should always be IPS

1) Number each vehicle and show direction of travel by arrow

2) Use solid line to show path of each vehicle before accident dotted line after accident
3) Show motorcycle or bicycle - 4) Show pedestrian
Show railroad by

Has This accident been reported to the insurance carrier by phone: Yes:
If so, to whom:
.Date:
.

Drivers Name and Signature:

No:

Supervisor:

Issued by

QHSE Manager

Revision No.

Authorised by

Chairman & CEO

Date

01st Jan, 10

Page 2 of 2