Accident Investigation Form and Seating Chart

Transcription

1 COMPANY MOTOR VEHICLE ACCIDENT REPORT DATE OF ACCIDENT: DRIVER S DATE OF BIRTH: DRIVER S LICENSE NUMBER: DRIVER S HOME DRIVER S DEPARTMENT/TERMINAL: DRIVER S HOME TELE DRIVER S WORK TELE VIN NUMBER: EST. REPAIR COST: YR. OF VEHICLE: MAKE: MODEL: # OF PASSENGERS: SEAT BELTS USED YES NO DESCRIBE VEHICLE DAMAGE: DRIVER S DRIVER S WORK DRIVER S HOME DESCRIBE VEHICLE DAMAGE: SECTION II OTHER VEHICLE DAMAGE LICENSE NUMBER: WORK TELE HOME TEL ESTIMATED REPAIR COST: YEAR OF VEHICLE: MAKE OF VEHICLE: MODEL: TAG AND STATE: VIN NUMBER: DRIVER S INSURANCE COMPANY & POLICY NUMBER: TELE OWNER S VEHICLE IS: CO OWNED RENTAL LEASED PRIVATELY OWNED SECTION III DEATH OR INJURY AGE: SEX: M F MARK IN TWO APPROPRIATE BOXES: DEATH DRIVER PASSENGER INJURED HELPER PEDESTRIAN TRANSPORTED BY: LOCATION IN VEHICLE: TRANSPORTED TO: FIRST AID GIVEN BY: PEDESTRIAN NAME OF STREET OR HIGHWAY: DIRECTION OF PEDESTRIAN: SB 2 (9/13) 2013 Nationwide Mutual Insurance Company Page 1 of 7

2 DESCRIBE WHAT PEDESTRIAN WAS DOING A TIME OF ACCIDENT (Crossing intersection with signal, against signal, diagonally, in roadway, playing, walking): DATE OF ACCIDENT: TIME OF ACCIDENT: SECTION IV ACCIDENT TIME AND LOCATION PLACE OF ACCIDENT (street address, city, state, zip; nearest landmark, distance nearest intersection. Kind of locality (industrial, residential, rural, etc.) Road description.): AM PM INDICATE ON THIS DIAGRAM HOW THE ACCIDENT HAPPENED Use one of these outlines to sketch the scene. Write in street or highway names or numbers. Vehicle 1 is your company s vehicle. Show NORTH with arrow. DESCRIBE WHAT HAPPENED (Refer to vehicles as 1, 2 and 3 with 1 being you company s vehicle. Please include information on posted speed limit, approximate speed of the vehicles, road conditions, weather conditions, driver visibility, condition of accident vehicles, traffic controls (warning light, stop signals, etc.) condition of light and drive actions (making U-turn, passing, stopped in traffic, etc.)): SB 2 (9/13) 2013 Nationwide Mutual Insurance Company Page 2 of 7

3 SECTION V WITNESS/PASSENGER WORK TELEPHONE: HOME TELEPHONE: BUSINESS HOME BUSINESS HOME SECTION VI PROPERTY DAMAGE NAME OF OWNER: WORK TELPHONE: HOME TELEPHONE: BUSINESS HOME NAME OF INSURANCE COMPANY: TELE POLICY NUMBER: ITEM DAMAGED: LOCATION OF DAMAGED ITEM: ESTIMATED COSTS: SECTION VII POLICE INFORMATION NAME OF POLICE OFFICER: BADGE NUMBER: TELE DEPARTMENT: PERSON CHARGED WITH ACCIDENT: VIOLATIONS: SECTION IX ACCIDENT INVESTIGATION DATA DID THE INVESTIGATION DISCOLOSE CONFLICTING INFORMATION: YES NO IF YES, EXPLAIN BELOW: PERSONS INTERVIEWED DATE: DATE: DATE: DATE: DATE: DATE: DATE: DATE: SB 2 (9/13) 2013 Nationwide Mutual Insurance Company Page 3 of 7

4 LIST ALL ATTACHMENTS BELOW: SECTION XII ATTACHMENTS REVIEWING OFFICIALS COMMENTS: SECTION XIII COMMENTS/APPROVAL ACCIDENT INVESTIGATOR SIGNATURE AND DATE: NAME PRINTED: TITLE: OFFICE: OFFICE TELE ACCIDENT REVIEWING OFFICIAL SIGNATURE AND DATE: NAME PRINTED: TITLE: OFFICE: OFFICE TELL ATTACH PHOTOS AS NECESSARY SB 2 (9/13) 2013 Nationwide Mutual Insurance Company Page 4 of 7

5 SCHOOL BUS SEATING CHART SB 2 (9/13) 2013 Nationwide Mutual Insurance Company Page 5 of 7

6 SCHOOL BUS SEATING CHART SB 2 (9/13) 2013 Nationwide Mutual Insurance Company Page 6 of 7

7 SCHOOL BUS SEATING CHART This information may not address all hazardous conditions at your location and does not warrant workplace safety or compliance with federal, state or local laws. SB 2 (9/13) 2013 Nationwide Mutual Insurance Company Page 7 of 7