Vehicle Collision – bookholyrides.com

General Information

Report Number *

Date of Incident *

Time of Incident *

Hours

Minutes

Street Address of incident *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Vehicle Involved

Vehicle Involved *Company VehiclePersonal VehicleOther

Vehicle Year, Make and Model *

Vehicle License Plate Number *

Driver Name *

Driver Phone *

Driver Email Address *

Incident Details

Type of Incident *Collision (with another vehicle, stationary object, etc.)Property Damage (vehicle damage, damage to property)Injury (driver, passenger, or pedestrian)Near Miss (potential accident)Breakdown/Mechanical Failure

Description of the Incident *

Was there any collision or property damage? ( If yes, describe the damage. If no leave this blank)

Were there any injuries? ( If yes, specify the injuries:)

Was law enforcement involved? ( If yes, provide the officer’s name and report number:)

Other Vehicles Involved

Year, Make and Model *

License Plate *

#1 Driver Name *

Year, Make and Model *

License Plate *

#2 Driver Name *

Was Immediate Actions Taken? (If yes, describe what action was taken)

Was the vehicle inspected for damages? ( If yes, provide details)

Person Reporting the Incident

Name *

Phone *

Email Address *

Are you an employee or contractor? *EmployeeContractorOther

Affirmation of Truthfulness and Willingness to Testify

YesNo

Date of completion

Vehicle Collision Report Form

General Information