No. / 2026 Accident Reporting Form Vehicle Fleet Management Practices / Incident Reporting Form Page 1/3 FULL NAME: Date of Birth: DRIVING LICENCE # POSITION: DEPARTMENT: SUPERVISOR Name: MOBILE PHONE: Hiring Date: EMAIL: BRAND / MODEL: PLATE NUMBER: YEAR: KILOMETERS: DETAILED DESCRIPTION OF THE DAMAGE ANY INJURY Yes No PM 3rd Party o o POLICE RECORD Yes No Ref No: DESCRIPTION OF INJURY: DATE OF ACCIDENT TIME OF ACCIDENT WERE YOU WEARING A SEAT BELT? Yes No DATE & TIME OF REPORTING: Trip Purpose: Business Private: LOCATION OF ACCIDENT: YOUR SPEED km/h VEHICLE USED PURPOSED Tool Car Benefit WHO IS RESPONSIBLE FOR THE ACCIDENT? PM Driver 3rd Party Shared
No. / 2025 Accident Reporting Form Vehicle Fleet Management Practices / Incident Reporting Form Page 2/3 NUMBER OF ACCIDENTS IN LAST 12 MONTHS (indicate the date of each accident) TIME IN CURRENT POSITION 6 Months< 6 Months< X <12 Months >12Months WAS THE ACCIDENT PREVENTABLE? Preventable Non-Preventable ESTIMATED COST FOR THE CAR REPAIR : LOSS OF TOBACCO PRODUCTS: Yes Non WEATHER CONDITION Sunny cloudy Rainy Windy Fog Clear Night OVERALL SIGNALIZATION Good Fair Bad ROAD CONDITION Water /Rain Pothole Gravel Sand Mud Good Other LIGHT CONDITION Day Night DETAILS OF THE ACCIDENT Collision with pedestrian Damage to parked vehicle Collision with vehicle Mechanical breakdown Collision with fixed object Vandalism, theft, crime Collision with animal/debris Natural disaster: Other: ROOT CAUSE OF ACCIDENT Driving too fast Violation of traffic rules Driving too close Under influence of substance Lane Change Fatigue Overtaking Road conditions Mistaken action Road debris Maneuvering / Parking Mechanical failure Lapse of attention / distraction Others:
No. / 2025 Accident Reporting Form Vehicle Fleet Management Practices / Incident Reporting Form Page 3/3 DESCRIPTION OF THE ACCIDENT IN YOUR OWN WORDS Illustrate position of the cars at time of collision SUPERVISOR’S SIGNATURE: DATE: DRIVER’S SIGNATURE: DATE: