Commercial Auto Accident

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Your Name *

Local Roots Vehicle ID *

Vehicle details if selected "Other" - year, make, model, VIN.. *

Driver Name *

Driver Address *

Driver Phone *

Driver Date of Birth *

YYYY

Driver SSN

What was damaged on the company vehicle? *

Please email any relevant photos to Diane dferrari@localrootslandscaping.com

Where is the vehicle now? Tow operator/location? *

Description of what happened, as much info as possible here. *

Date, time and location of the accident. *

Were the police called/ on scene? EMS or Fire? If so, department(s) responding. *

Incident number from police if any. *

Injuries to employee(s) in or around vehicle? *

Injuries to others, in another vehicle, pedestrian etc. *

If there are injuries to an employee driver or passenger as a result of the accident, we will also need: Name, address and phone number, soc. Sec number, D/O/B Seat belt use, Injury details.

What Urgent Care or hospital they went to, address and phone of treatment facility and Dr that treated injured employee.

Other Party Information to get if possible:

For each vehicle involved Driver name, address and phone number. Year, make and model of other vehicle(s). Name of their insurance carrier and the policy number. This can be found on their insurance ID card. *

If there are any witnesses not involved in the actual accident, get a name, address and phone number. What did they see? *

Any employees injured need to fill out the Injury Form as well.

This can be found on the employee portal under "Safety"

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