City of St. Joseph Vehicle Accident Report

Welcome to the City of St. Joseph’s Online Vehicle Accident Report. Use this form to report all Accidents involving City Vehicles or Motor Driven Equipment. A supervisor must submit the form. This form may NOT be completed by the employee operating the vehicle or equipment at the time of the accident. This form is required even if a police report was filed. Note: This is an official report. Please review all entries for accuracy prior to selecting the “Submit” option. Failure to comply may result in disciplinary action up to and including termination. Please contact Risk Management at 236-1478 if you have any questions. Please submit a copy of any applicable police report to Risk Management as soon as it is available.

YOU MUST CLICK THE SUBMIT BUTTON AT THE BOTTOM OF THE PAGE IN ORDER FOR THE REPORT TO BE SUBMITTED PROPERLY.

(NOTE: Please use the TAB key, or the mouse, to move between fields.)

* = required

1. *Date of Accident (mm/dd/yy)
2. *Time of the Accident (hh:mm) AM PM
3. Police Report Number (if available)
4. *Citation/Summons Issued? yes no

City Vehicle Information

1. *Vehicle Year (YYYY)
2. *Vehicle Make Choose a vehicle make None Capacity Chevrolet Chrysler Cub Cushman Dodge Elgin Ford Freightliner GMC Harley Davidson International Isuzu Jeep Kenworth Pierce Plymouth Seagrave Smeal Spartan Sterling Subaru Volvo Winnebago
3. *Vehicle Model
4. *VIN #
5. *License Plate Number
6. *City Driver Name
7. *Home Address (Street)
8. *Address (City)
9. *Address (State-2 character abbr.)
10. *Zip Code
11. *Home Phone Number (xxx-xxx-xxxx)
12. *Work Phone Number (xxx-xxx-xxxx)
13. *City Driver DOB (mm/dd/yy)
14. *Driver's License Number
15. *Name of Immediate Supervisor
16. *Description of Damage (City vehicle)

Other Property or Vehicle

1. Description of Property
2. Vehicle Year (YYYY)
3. Vehicle Make Choose a vehicle make None Capacity Chevrolet Chrysler Cub Cushman Dodge Elgin Ford Freightliner GMC Harley Davidson International Isuzu Jeep Kenworth Pierce Plymouth Seagrave Smeal Spartan Sterling Subaru Volvo Winnebago
4. Vehicle Model
5. Driver Name (if applicable)
6. Address (Street)
7. Address (City)
8. Address (State-2 character abbr.)
9. Zip Code
10. Phone Number (xxx-xxx-xxxx)
11. Alternate Phone Number (xxx-xxx-xxxx)
12. Is Vehicle Insured? yes no N/A
13. Insurance Company
14. Policy Number
15. Insurance Company Phone Number (xxx-xxx-xxxx)
16. Owner Name
17. Owner Address (Street)
18. Owner Address (City)
19. Owner Address (State-2 character abbr.)
20. Owner Zip Code
21. Owner Phone Number (xxx-xxx-xxxx)
22. Owner Alt. Phone Number (xxx-xxx-xxxx)
23. Description of Damage

Injured (Non-Employee)

1. First Injured Name
2. Address (Street)
3. Address (City)
4. Address (State-2 character abbr.)
5. Zip Code
6. Phone Number (xxx-xxx-xxxx)
7. Description of Injury

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8. Second Injured Name
9. Address (Street)
10. Address (City)
11. Address (State-2 character abbr.)
12. Zip Code
13. Phone Number (xxx-xxx-xxxx)
14. Description of Injury

Witness

1. Name
2. Address (Street)
3. Address (City)
4. Address (State-2 character abbr.)
5. Zip Code
6. Phone Number (xxx-xxx-xxxx)

Accident Detail

1. *Location 1 (Street Address)
2. Location 2 (Decription of Area)
3. *Description of Accident
4. *Were Photos Taken? yes no
5. Are there additional reports related to this accident? yes no N/A
6. If "yes", were they forwarded to Risk Management? yes no N/A
7. Comments
8. *Name of Person Submitting Report