Southland Industries

VEHICLE CLAIM

If you are involved in a vehicle collision, contact your division safety representative immediately. Please complete this form
at the scene of the collision. Send the completed form to your division safety representative and to Pat Parra in the Corporate
Safety Department. If Pat Parra is not available, please contact Reyann Contreras.

Primary Contact: Division Safety Representative
Secondary Contact: Pat Parra, Corporate Safety Coordinator

[email protected]
Phone: 714) 901-5800, Ext 7154
Cell: 949) 892-9027
Fax: 714) 908-3314

Instructions

1. Stop at once! Check for personal injuries and call or send for emergency personnel (Police, Fire Department, Ambulance).

2. Tactfully get the name and addresses of witnesses, using the space provided on this form.

3. Do not argue. Make no statement except to the proper authorities. Sign nothing except the official police reports.

4. Note all details and complete this report. Do not plead guilty to any charge with out consulting with your employer.

5. When police arrive, get the name and badge number of the officers and note them on this report.

IN THE EVENT OF A SERIOUS INJURY, CONTACT YOUR DIVISION SAFETY REPRESENTATIVE OR THE CORPORATE SAFETY DEPARTMENT IMMEDIATELY!!!

Date of Incident *

Division/Job No. *

Vehicle No *

Vehicle Year *

Make/Model *

Vehicle Color *

License Plate No. *

Vin No *

Jobsite.

Foreman Email:

Southland Employee Driver Information

Name *

Address *

Home Phone No *

Work Cell No *

Drivers License Number *

Date of Birth *

Passenger(s)? Yes No

If yes, please list passenger(s) and relationship.

Other Driver's Information

Driver's Name

Driver's Address (include city and state)

Driver's Phone No.

Vehicle Owner's Name

Owner's Address (include city and state)

Owner's Phone No.

Vehicle Year

Make/Model

Vehicle Color

License Plate No.

Vin No

Other Driver's Insurance Co

Ins. Co. Phone No

Ins. Policy No

Passenger(s)? Yes No

If yes, please list passenger(s) and relationship.

Third Driver's Information (If Applicable)

Driver's Name

Driver's Address (include city and state)

Driver's Phone No.

Vehicle Owner's Name

Owner's Address (include city and state)

Owner's Phone No.

Vehicle Year

Make/Model

Vehicle Color

License Plate No.

Vin No

Other Driver's Insurance Co

Ins. Co. Phone No

Ins. Policy No

Passenger(s)? Yes No

If yes, please list passenger(s) and relationship.

Police Information

Officer's Name

Headquarters

Badge No

Police Report No

Incident Information

Time of Incident *

Weather

Location (include city and state) *

Kind and Condition of Pavement

Direction of SI Vehicle's Travel

SI Driver's Speed

Direction of Other Vehicle's Travel

Other Vehicle's Speed

Direction of Third Vehicle's Travel

Third Vehicle's Speed

Description of Incident (Include Length and Position of Skid Marks) *

Description of Damage to SI Vehicle

Is S.I. vehicle safely drivable? Yes No

If no, was it towed? Yes No

Vehicle was towed by:(include name and address):

Vehicle was towed to:(include name and address):

Description of Damage to Other Vehicle

Description of Damage to Third Vehicle

Personal Injuries

Name

Address

Phone No.

Injury

Name

Address

Phone No.

Injury

Name

Address

Phone No.

Injury

Witness(es)

Name

Address

Phone No.

Name

Address

Phone No.

Name

Address

Phone No.

Upload Image(s)
(Max 5 files allowed)

Diagram of Collision

Clear Diagram

IF POSSIBLE, TAKE PHOTOGRAPHS OF THE VEHICLE(S) AND COLLISION SITE. FORWARD THE DISPOSABLE CAMERA, DEVELOPED FILM OR DIGITAL IMAGES TO PAT PARRA AT THE CORPORATE SAFETY DEPARTMENT.