Incident Reporting Form

Please fill out this form as completely as possible.

HURRICANE INCIDENT NUMBER
Person Completing Form Person Completing Form First Last
Driver Name Driver Name First Last
Driver Phone Number Driver Phone Number - ### - ### ####
Truck Number:
Trailer Number:

Put trailer number even if there is no damage to the trailer or load. This is for insurance purposes. If the truck is bob-tailing, put in NO Trailer - Bobtail
Date of Incident Date of Incident / MM / DD YYYY
Time Time : HH MM AM/PM
Date Reported Date Reported / MM / DD YYYY
Review Date Review Date / MM / DD YYYY
Location Address of Incident Location Address of Incident
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Roadway (Rt#, Street, Intersecting Hwy)
Landmarks (Near bridge, Mile post etc...)
INCIDENT DESCRIPTION
Callers Description of the Event - Include type of damage to equipment as well.
Driver Description of Event - Include type of damage to equipment as well.
INVESTIGATION
Was Accident Investigated by Police?

Was Accident Investigated by Police? Yes No
Police Department
Badge #
Officer Name Officer Name First Last
Citation Issued?

Citation Issued? Yes No Unknown
List person(s) cited or arrested & charges.
Cost of Repairs
File Upload (images, supporting documents etc...)