Form Center

Step One

Notification of Vehicle Accident or Work Related Injury
Please answer all applicable questions to the best of your ability.
Date of Report
Date of Report
Reporting Department*
Employee Information
Employee First & Last Name
Employee Address (Street, City, State, Zip)
Employee Phone Number
Employee Email Address
Date of Birth
Date of Birth
Hire Date
Hire Date
Continue

Vehicle Accident Details
Complete this section if employee was involved in a vehicle accident. Complete this section AND injury section if accident also includes injury.
Date & Time of Accident
Date & Time of Accident
Date & Time of Accident
Accident Location
Vehicle Make/Model (Village #)
Was vehicle responding to emergency?
1. Yes
2. No
Describe cause of the accident
Describe the damage to Village vehicle
List any other Village employees in the vehicle or indirectly involved (witnesses, etc)
Describe damage to other vehicles involved
Name and Address of other vehicle driver
Phone number
Email
Insurance Information
Insured by and Policy #
Was a citation issued?
1. Yes
2. No
If yes, to whom?
Report #
Describe damage to private property (if applicable)
Upload pictures, police report or other pertinent files.
Continue |Go Back

Date & Time of Injury
Date & Time of Injury
Date & Time of Injury
Describe the cause of the injury? What was the employee doing at the time of injury?
Body part or parts sustaining injury
Please be descriptive, e.g. left arm, right leg, etc.
Did anyone witness the incident/injury?
Type of Injury
Choose the best option
1. Strain or sprain
2. Laceration
3. Fracture or break
Did the employee seek medical attention?
1. Yes
2. No
If yes, where did the employee receive medical attention?
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Report prepared by: (Electronic Signature)

Leave This Blank: