Skip to content
PAY YOUR BILL
CALL (515) 288-0924
Services
Sanitary Portable Restrooms
Special Event Portable Restrooms
Sanitary Restrooms
Sanitary Hand Cleansing Stations
Shower Trailer
Sanitary Restroom Trailers
Roll Off Dumpsters
Grease Trap Cleaning
Choosing The Right Portable Bathroom
Solar Surveillance Towers (Sst)
Kitchen Exhaust & Hood Cleaning
About
Service Area
Join Our Team
Services
Sanitary Portable Restrooms
Special Event Portable Restrooms
Sanitary Restrooms
Sanitary Hand Cleansing Stations
Shower Trailer
Sanitary Restroom Trailers
Roll Off Dumpsters
Grease Trap Cleaning
Choosing The Right Portable Bathroom
Solar Surveillance Towers (Sst)
Kitchen Exhaust & Hood Cleaning
About
Service Area
Join Our Team
request service
Accident Form
Step
1
of
6
- Employee Accident Info
16%
EMPLOYEE’S NAME
(Required)
First
Last
DATE OF BIRTH
(Required)
MM slash DD slash YYYY
DATE OF ACCIDENT
(Required)
MM slash DD slash YYYY
TIME OF ACCIDENT
(Required)
Hours
:
Minutes
AM
PM
AM/PM
LOCATION OF ACCIDENT
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
TYPE OF ACCIDENT
(Required)
VEHICULAR
PERSONAL
PROPERTY
OTHER
Please Explain Other Type of Accident
(Required)
COMPANY VEHICLE #:
(Required)
YEAR:
(Required)
MAKE
(Required)
MODEL:
(Required)
LICENSE PLATE #:
(Required)
Driver Info
NAME OF OTHER DRIVER
DRIVER’S LICENSE #:
LICENSE PLATE#:
INSURANCE COMPANY
POLICY NUMBER
Actions
Edit
Delete
There are no
Entries.
Add Entry
Maximum number of entries reached.
DESCRIBE ACCIDENT IN DETAIL WITH DIAGRAM
Upload any images If Needed
Accident Images
Drop files here or
Select files
Accepted file types: jpg, png, gif, heic, jpeg, mp4, Max. file size: 12 MB, Max. files: 8.
WERE ANY VEHICLES TOWED FROM THE ACCIDENT SCENE?
(Required)
Yes
No
WERE THERE ANY INJURIES:
(Required)
Yes
No
WERE THERE ANY WITNESSES?
(Required)
Yes
No
Witness List
Name
Address
Phone
SAW ACCIDENT
Actions
Edit
Delete
There are no
Entries.
Add Entry
Maximum number of entries reached.
WAS THE ACCIDENT PREVENTALBE?
(Required)
Yes
No
WAS ACCIDENT CAUSED BY AN UNSAFE ACT?
(Required)
Yes
No
PLEASE EXPLAIN HOW IT WAS PREVENTABLE
(Required)
WHAT WERE THE PRIMARY CAUSES OF THE ACCIDENT
(Required)
(HUMAN, MECHANICAL, ENVIRONMENTAL i.e. weather conditions, mud, ice, steep ground, etc.) PLEASE EXPLAIN
DESCRIBE DAMAGE TO YOUR VEHICLE:
(Required)
DESCRIBE DAMAGE TO OTHER VEHICLE(S):
(Required)
WERE YOU USING PROTECTIVE CLOTHING & EQUIPMENT
(Required)
Yes
No
(HARD HAT, SAFETY GLASSES, SEAT BELT, ETC.)
WAS IT AVAILABLE?
(Required)
Yes
No
DESCRIBE THE STEPS YOU TOOK AFTER THE ACCIDENT:
(Required)
PERSONAL INJURY – IF THE ACCIDENT INVOLVED PERSONAL INJURY/INJURIES, PLEASE COMPLETE 3, 6, 7, 8, 9, 12 & 13 OF THIS ACCIDENT FORM.
DESCRIBE INJURY. GIVE PART(S) OF BODY AFFECTED
(Required)
(FOR EXAMPLE, HEAD, SHOULDERS, LIMBS, BODY, OTHER):
TYPE OF TREATMENT RECEIVED
(Required)
FIRST AID
MEDICAL
HOSPITALIZATION
OTHER
PLEASE EXPLAIN OTHER TREATMENT
(Required)
EMPLOYEE SIGNATURE