JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Gulick Trucking -
INCIDENT REPORT
ACCIDENT / INCIDENT REPORT
I certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld.
I understand that this claim may be refused if the information submitted is untrue, inaccurate, incomplete or material evidence, statements, observations, etc. is concealed or withheld.
All questions below must be answered, in your words and to the best of your recollection, without reference to additional documents, photos or statements.
***
DO NOT USE ***
- "see photos", "sent in email", "already provided", "refer to police report", "scanned with paperwork", etc. ***
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name & Phone #
*
(
FIRST AND LAST NAME OF
GULICK DRIVER/CONTRACTOR, INCLUDING PHONE NUMBER)
Your answer
Truck # & Trailer #
*
(GULICK ASSIGNED TRUCK AND TRAILER NUMBER / LEASED SUB-HAUL EQUIPMENT)
Your answer
Date/Time of Incident
*
(DATE AND TIME BASED ON CURRENT TIME ZONE LOCATION -
NOT LOGBOOK TIME!
)
MM
/
DD
/
YYYY
Time
:
AM
PM
Location - City & State
*
(INCLUDE ADDRESS, CITY, AND STATE AND/OR NEAREST CROSS STREET)
Your answer
Incident Description
*
BE VERY SPECIFIC
(ALSO SEND/TEXT PICTURES OF THE SURROUNDING AREA)
Your answer
Damage to Your Truck and/or Trailer
*
BE SPECIFIC
(ALSO
SEND/TEXT
PICTURES FROM MORE THAN ONE DISTANCE AND ANGLE)
Your answer
Their Damages
*
BE SPECIFIC
include Vehicle and/or Property Damage (ALSO
SEND/TEXT
PICTURES FROM MORE THAN ONE DISTANCE AND ANGLE)
Your answer
Their Contact Info
*
PROVIDE CONTACT INFORMATION - NAME AND PHONE NUMBER (ALSO
SEND/TEXT
PICTURES OF THEIR
LICENSE, REGISTRATION, AND INSURANCE
DOCUMENTATION)
*** Get Truck/Trailer #'s, plates and DOT # ***
Your answer
Their Insurance Info
*
(PROVIDE COMPANY NAME,
PHONE AND POLICY #
)
Your answer
Passengers/Witnesses
*
Anyone in or around the area (PROVIDE CONTACT INFORMATION -
NAME AND PHONE NUMBER
)
Your answer
Police Contact Info
*
Department and Officers Name (ALSO REQUEST BADGE# OR ID# AND REPORT #)
Your answer
List Any/All Injuries
*
(INCLUDE ANY OBSERVATIONS OF INJURED PERSONS)
Your answer
Any Vehicles Towed?
*
(INCLUDE TOW COMPANY INFO UNDER DAMAGE TO GULICK TRUCK)
Yes
No
Unknown
Were You Cited?
*
(SEND IN ALL PAPERWORK YOU RECEIVED - VIA TEXT)
*** ADVISE SAFETY ASAP ***
Yes
No
Load #
*
Your answer
Any Dashcam footage?
*
Yes
No
Maybe
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
