Accident Report Form Page 2
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How did the incident occur? Describe incident with all available details. Use separate sheet of paper (NOT back of this
page) if necessary to provide details.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Diagram the roadway/location: The position of vehicles, pedestrians, objects and signal lights/signs and show the path of
movement of all moving vehicles or pedestrians involved. DIAGRAM IS REQUIRED. Use separate sheet, if necessary.
Driver Signature: ______________________________________________________ Date: __________________
Staffmark Branch Representative Reviewing Report: ________________________________________________
Applicable in California: For your protection, California law requires the following to appear on this form.
It is unlawful to (a) Present or cause to be presented any false or fraudulent claim for payment of a loss under a contract or insurance; and/or (b)
Prepare, make or subscribe, in writing, with intent to present or use the same or to allow it to be presented or used in support of any such claim.
A violation any provision of this section is punishable by imprisonment in the state prison, or by a fine not exceeding one thousand dollars ($1,000) or
both.
Applicable in Florida, Idaho and New York: Any person who knowingly, and with intent to injury, defraud or deceive any insurance company, files a
statement of claim containing false, incomplete or misleading information is guilty of a felony.*
rd
rd
nd
st
Florida – 3
Degree Felony
New York – Insurance Fraud in 3
Degree – Class A misdemeanor; 2
Degree – Class E Felony; 1
Degree – Class D
Felony.
Issued By:
Issue Date:
Revision Date:
Form #:
Page 2 of 2
Safety
05/01/2004
02/08/2012
TRANS 138
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