Park Construction Co.



	Report of Vehicle/Property Damage

REPORT OF VEHICLE/PROPERTY DAMAGE

IMPORTANT!

All work related injuries, utility line damage or accidents must be reported immediately. Fill out the accident reporting form and call the information into the office or safety director immediately. FAX or mail a copy of the completed form into the office within 24 hours.

To report an accident during normal business hours contact Tammy Johnson at 701-662-2680.

To report an accident after normal business hours contact the Safety Director at 701-741-3092.

It is critically important to report accidents immediately. Insurance companies do have the right to refuse claims that are not reported in a timely manner.

This form is to be filled out immediately for every accident or damaged utility on the job.

PARK Vehicle/Property
Equipment No.:
Description:
Extent of Damage:
Driver/Operator:
Phone No.:
Other Vehicle/Property
Property Damaged:
License No.:
Extent of Damage:
Name of Driver/Owner:
Phone No.:
Address:
Name of Owner's Insurance Company:
Time and Place
Date of Accident:
Time:	AM PM
Accident occured at:
City/State:
Was Report Made to Police/Utility Company?	Yes No Where? Was the utility marked? Yes No Call One Control Number:
Injured Persons
Name:
Phone:
Name:
Phone:
Name:
Phone:
Witnesses
Name:
Phone:
Name:
Phone:
Describe Accident
Weather Condition:
Road Condition: