Driver Accident Report Form

I am reporting a *

Loss of time/injury
First aid incident
Vehicle Accident

Person Reporting Incident *

First

Last

Person Involved in Incident *

First

Last

Other Perspons Involved In Accident

License Plate Numbers of all Vehicles/Equipment involved *

First Plate #
Second Plate #
Third Plate #
Fourth Plate #

Date / Time of Incident *

Date

Time

Location of Incident

Please describe the event in detail.

Was damage done to affixed property? *

Yes
No

Any damage done to buildings and or permanent structures.

Signature *

By signing and submitting this report I agree and abide by all of the state laws of Oregon and the driver bylaws and dot regulations set here forth by Long Haul Trucking LLC

Name

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