Report - Auto Accident

Person Submitting the Report*

First NameLast Name

E-mail address

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Incident*

Date

Hour MinutesAM/PM Option

Location of Incident

Street Address

Street Address Line 2

CityState

Zip Code

Were there any injuries?*

NoYes

Did the Police arrive?*

YesNo

In your own words, describe the accident. What was each vehicle doing leading up to the accident, during and after the accident.*

Describe the property damage that occurred, if any (not including vehicle damage)

(Injuries will be addressed later)

Video Description of the Incident

If you prefer, you may create a video of your description of what happened. Text or e-mail them to the Safety Manager at 303-521-3818 / Safety@ColoradoHardscapes.com.

After you submit this form you will see these options again.

If your personal vehicle was involved send a picture of your insurance card (front and back) and driver's license. See below to submit pictures.

Company or Employee Vehicle Involved

List any Passengers who were in the vehicle (not including the driver)

Number of OTHER vehicles involved in accident*

Instead of filling out the other vehicle's information below you may submit a picture of the other driver's license and insurance card (front and back). If there were multiple other drivers, include every driver's information.

Be sure to include a picture of the license plate of the other vehicle(s).

See below to submit pictures.

Other Vehicle #1 - Vehicle & Driver Information

Other Vehicle #2 - Vehicle & Driver Information

Other Vehicle #3 - Vehicle & Driver Information

Other Vehicle #4 - Vehicle & Driver Information

Other Vehicle #5 - Vehicle & Driver Information

Law Enforcement Agency Investigating:

(Type "None" if police were not there)

Officer Name:

Was there a citation issued?

YesNo

Who was the citation issued to?

Upload pictures here or text or e-mail your pictures to the Safety Manager at 303-521-3818 / Safety@ColoradoHardscapes.com. After you submit this form you will see these options again.

File Upload

Do not be surprised if you receive a call from our insurance company - Cottingham & Butler - investigating this accident. Please be cooperative as they are there for our benefit in handling this claim.

You might also receive a call from the other insurance company. Cooperate, but at no time admit fault. Let the insurance company do it's investigation to determine fault.

How many people were injured?

Injured Person #1

First NameLast Name

Injured Person #1 Phone Number

Describe the injury to Person #1

Injured Person #2

First NameLast Name

Injured Person #2 Phone Number

Please enter a valid phone number.

Describe the injury to Person #2

Injured Person #3

First NameLast Name

Injured Person #3 Phone Number

Describe the injury to Person #3

Injured Person #4

First NameLast Name

Injured Person #4 Phone Number

Please enter a valid phone number.

Describe the injury to Person #4

Injured Person #5

First NameLast Name

Injured Person #5 Phone Number

Describe the injury to Person #5

Injured Person #6

First NameLast Name

Injured Person #6 Phone Number

Please enter a valid phone number.

Describe the injury to Person #6

Injured Person #7

First NameLast Name

Injured Person #7 Phone Number

Describe the injury to Person #7

Injured Person #8

First NameLast Name

Injured Person #8 Phone Number

Please enter a valid phone number.

Describe the injury to Person #8

Injured Person #9

First NameLast Name

Injured Person #9 Phone Number

Describe the injury to Person #9

Injured Person #10

First NameLast Name

Injured Person #10 Phone Number

Please enter a valid phone number.

Describe the injury to Person #10

Were emergency responders involved? If so, provide contact information and any report numbers

Report Submitted by:

First NameLast Name

Signature

I certify that the statements contained in this report are true to the best of my knowledge and belief.

Date Submitted

Date

Hour MinutesAM/PM Option

Auto Accident Report Form

What Happened?

Vehicles Involved

Pictures

Injuries