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Company Dashboard – Login
HBI DRIVER’S ACCIDENT REPORT
* Report all collisions promptly, especially those involving serious injury or death
* Carefully examine all damage to vehicles and property
Your Vehicle
Driver's Name
Company Name
Policy #
Phone #
Driver's Lic. #
Lic. Plate #
Photo of Driver's License
Drop files here or
Select files
Max. file size: 120 MB, Max. files: 1.
Make of Vehicle
Model
Year
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Damage to your vehicle?
Yes
No
If Yes, Where?
Location of Accident
Location of Accident
Street Address
Address Line 2
City
State / Province / Region
Injuries
Are you Injured?
Yes
No
If Yes, describe injury
Conditions
Pavement
Dry
Wet
Ice
Snow
Weather
Visibility
Traffic Control
Lights
Signs
None
Police
Police Investigation?
Yes
No
Name of Police or Sheriff Dept.
Citation Issued?
Yes
No
To Whom
Other Vehicle
Driver's Name
Company Name
Policy #
Phone #
Photo of Insurance Card
Drop files here or
Select files
Max. file size: 120 MB, Max. files: 1.
Driver's Lic. #
Lic. Plate #
Photo of Driver's License
Drop files here or
Select files
Max. file size: 120 MB, Max. files: 1.
Make of Vehicle
Model
Year
Damage to other vehicle?
Yes
No
If Yes, Where?
Other Vehicle Injuries
Are they Injured?
Yes
No
If Yes, describe injury
Witnesses
Witness Name, Address, and Phone #
Add
Remove
Property Damage Other Than Vehicles
Was there property damage other than vehicles?
Yes
No
Owner
Address
Street Address
Address Line 2
City
State / Province / Region
Phone
What was damaged
Location of property
List All Passengers or Other Persons Involved
Were there any other passengers or other persons involved? (1)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Were there any other passengers or other persons involved? (2)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Were there any other passengers or other persons involved? (3)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Were there any other passengers or other persons involved? (4)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Were there any other passengers or other persons involved? (5)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Were there any other passengers or other persons involved? (6)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Were there any other passengers or other persons involved? (7)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Were there any other passengers or other persons involved? (8)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Were there any other passengers or other persons involved? (9)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Were there any other passengers or other persons involved? (10)
Yes
No
Name, Address, and Phone #
Name
Address
Phone Number
Add
Remove
Where
Your Vehicle
Other Vehicle
Pedestrian
Injured?
Yes
No
If yes, describe
Describe what happened
(Required)
Photos of Accident (at least 5) include surroundings
(Required)
Drop files here or
Select files
Max. file size: 120 MB.
Drivers Signature
Reset signature
Signature locked. Reset to sign again
Additional Email 1
Send a notification to an additional email
Additional Email 2
Send a notification to an additional email
