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Driver Name
*
First
Last
Driver's license #
*
Date of accident
*
Change this to a date/time field when the real version is installed.
Location
*
Single Line Text
Make, year, and equipment #:
*
Ticketed?
*
Yes
No
Truck VIN #:
*
Trailer VIN #:
*
Injury?
*
Yes
No
If the answer to the previous question is "Yes", please stat the reason:
Police report #:
*
Vehicle #2 name:
*
First
Last
Vehicle #2 address:
switch this to address field type when real version is installed.
Vehicle #2 make/year:
License plate #:
Driver's license #:
accident/citation: #2 to
Insurance:
Names of all occupants:
Names of all witnesses:
Phone number:
switch this to Phone # field when real version is installed.
Description of accident/citation:
*
Damage to ABD vehicles:
*
Minor
Medium
Heavy
Please explain your answer to the previous questions:
*
Damage to other vehicles:
Minor
Medium
Heavy
If you answeed yes to any of the choice in the previous question, please explain that answer here:
Manager
*
Routing
J
SPG
TMS
KMK
AS
NF
HR
Today's date:
switch to date/time field when real version is installed
Employee:
*
First
Last
Submit
Are you over 21 years of age?
Beer Me!
Root Beer Me!
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