TEP Accident Report Form |

Type(Required)

Injury
Illness
Vehicle
Property Damage

Employee Information

Name(Required)

First Last

Phone(Required)

Last (4) SSN(Required)

Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

Sex

Male
Female

Job Title(Required)

Division(Required)

Employment Information

Type(Required)

Regular, Full-Time
Regular, Part-Time
Temporary
Seasonal
Non-Employee

Length of Employment(Required)

< 1 Month
1 - 5 Months
6 Months - 5 Years
5+ Years

Time in Occupation (At Time of Incident)(Required)

< 1 Month
1 - 5 Months
6 Months - 5 Years
5+ Years

Accident Information

Date of Accident(Required)

Time of Accident(Required)

:

Location of Accident(Required)

Street Address City State ZIP Code

Person(s) Involved in Accident (Name & Phone Number)

Detailed Accident Description(Required)

Medical Treatment (State "none" if no Treatment was Provided)

Medical Treatment Provider

Name Address City State ZIP Code

Provider Phone Number

Witness Information

Name

Name Phone Number

Address

Street Address City State ZIP Code

Property Damage Information

Description of Damaged Property

Name

Owner Name Phone

Address

Street Address City State ZIP Code

Police Report #

Police Department

Vehicle Damage Information

Make/Model

Year

TEP Vehicle #

TEP Responsible Employee

Weather / Traffic Conditions

Was TEP Employee cited?

Yes
No

If Yes, What Charge?

Was Another Driver Cited?

Yes
No

If Yes, What Charge

Police Report #

Police Department

Other Vehicle Information (non-TEP Vehicle)

Driver Name Phone

Name

Insurance Company Policy #

Address

Street Address City State ZIP Code

Vehicle Make/Model/Year

Passengers (List Names)

Consent

I agree to the privacy policy.

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Phone

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