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2. 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.
4. Date of Accident*
   Date of Accident

   Date of Accident
6. Police Report Number (if available)
8. Citation/Summons Issued?*

   1. Yes
   2. No
12. City Vehicle Information
14. Vehicle Year (YYYY)*
16. Vehicle Make*
    -- Select One --NoneCapacityChevroletChryslerCubCushmanDodgeElginFordFreightlinerGMCHarley DavidsonInternationalIsuzuJeepKenworthPiercePlymouthSeagrave
18. Vehicle Model*
20. VIN #*
22. License Plate Number*
24. City Driver Name*
26. Home Address (Street)*
28. Address (City)*
30. State*
    -- Select One --ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
32. Zip Code*
34. Home Phone Number*
36. Work Phone Number*
38. City Driver DOB*
    City Driver DOB
40. Driver's License Number*
42. Name of Immediate Supervisor*
44. Description of Damage (City vehicle)*
48. Other Property or Vehicle
50. Description of Property
52. Vehicle Year (YYYY)
54. Vehicle Make
    -- Select One --None
56. Vehicle Model
58. Driver Name (if applicable)
60. Address (Street)
62. Address (City)
64. State
    -- Select One --ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
66. Zip Code
68. Phone Number
70. Alternate Phone Number
72. Is Vehicle Insured?
74. Insurance Company
76. Policy Number
78. Insurance Company Phone Number
80. Owner Name
82. Owner Address (Street)
84. Owner Address (City)
86. State
    -- Select One --ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
88. Owner Zip Code
90. Owner Phone Number
92. Owner Alt. Phone Number
94. Description of Damage
98. Injured (Non-Employee)
100. First Injured Name
102. Address (Street)
104. Address (City)
106. State
     -- Select One --ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
108. Zip Code
110. Phone Number
112. Description of Injury
116. Second Injured Name
118. Address (Street)
120. Address (City)
122. State
     -- Select One --ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
124. Zip Code
126. Phone Number (xxx-xxx-xxxx)
128. Description of Injury
132. Accident Detail
134. Location 1 (Street Address)*
136. Location 2 (Description of Area)
138. Description of Accident*
140. Were Photos Taken?*

     1. Yes
     2. No
142. Are there additional reports related to this accident?

     1. Yes
     2. No
     3. N/A
144. If "yes", were they forwarded to Risk Management?

     1. Yes
     2. No
     3. N/A
146. Comments
148. Name of Person Submitting Report*
Leave This Blank:


150. 1. Receive an email copy of this form.
151. Email address

     This field is not part of the form submission.

152. Submit

* indicates a required field