Please complete all sections. All fields are required unless specified as optional. If more space needed for any section, use the Other Notes field. Select Company*- Select -Container ConnectionHuber LogisticsLogistics InsightSouthern Counties ExpressSpecialized RailUniversal Capacity SolutionsUniversal Dedicated of ArlingtonUniversal Dedicated of DetroitUniversal Dedicated of Ft. WayneUniversal Dedicated of Neb & WisUniversal Dedicated of RomulusUniversal Dedicated of SmyrnaUniversal Intermodal Services, Inc.Universal Logistics Solutions Canada, LtdUniversal-OfficeWestport AxleWestport MachiningMaintenance InsightRuedas Grandes TransportesUniversal Dedicated of GreerUniversal AggregateSelect Region*- Select -NorthSouthBrokered Carrier*NoYesName of Motor Carrier* DOT Number* Person Completing This FormYour First Name* Your Last Name* Your Email* Phone Number*Ext. Terminal/Agent #* Call In Time* AM/PM*AMPMTime Zone*ESTCSTMSTPSTDomiciled City/State* Contractor / Driver InformationContractor / Driver First Name* Contractor / Driver Last Name* Contractor / Driver Phone Number*Street Address* City/State* Zip Code* Job Title*- Select -Company DriverAgency TempIndependent ContractorOffice EmployeeNon Office EmployeeEmployed By* CDL #* Trainee (Only if in Training Program)*- Select -NoCDPFDPT2TDash Cam in Vehicle*- Select -YesNovehicle Passenger*- Select - YesNoPassenger Name* Was Passenger Injured?*- Select -YesNoPassenger Contact Info* Injury InformationWas Driver Injured*- Select -YesNoDate of Birth MM slash DD slash YYYY Street Address* City/State* Zip Code* County* Job Title*- Select -Company DriverAgency TempIndependent ContractorOffice EmployeeNon Office EmployeeSex*- Select -MaleFemaleNumber Of Dependents*012345Start Date* MM slash DD slash YYYY Time They Began Work* AM/PM* AMPMTime Zone They Began Work* ESTCSTMSTPSTTime Injury Occured* AM/PM* AMPMTime Zone Injury Occurred* ESTCSTMSTPSTSpecify where the event occurred* Was the individual wearing any person protective equipment (PPE)*- Select -YesNoType of PPE Worn* Witnesses To the Event* What Were They Doing Before Injury?*How Did The Injury Happen*Objects Directly Causing Injury*Injury Description*Any Loss Of Eyes*- Select -YesNoAny Loss of Appendages*- Select -YesNoDid The Individual*- Select -Refuse Medical TreatmentProceed to a Medical ClinicGet Taken or Proceed to a HospitalWere they*- Select -Treated then ReleasedHospitalizedClinic or Hospital Name* Clinic or Hospital Street Address* City/State/Zip* Clinic Phone Number*Are Work Restrictions Anticipated*- Select -YesNoIs loss of time at work anticipated*- Select -YesNoOther NotesAccident InformationAccident Description*Was Equipment Towed From Scene?*- Select -YesNoType Of Equipment Involved*- Select -Tractor/TrailerForkliftTuggerStraight TruckCargo VanHeavy LiftOtherDescribe* Tractor # Equipment #* Company Equipment?*- Select -YesNoDescribe Damage*Trailer #* Trailer Type*No TrailerFlatbedVanIntermodalCompany Trailer?*- Select -YesNoTrailer Owner* Describe Damage*Was the Trailer Towed From Scene*- Select -YesNoTow company information if receivedCargo Description and Value if known*Was Cargo Damaged*- Select -YesNoUnder Dispatch*- Select -YesNoWhat is the Heading* Terminal/Home After DeliveryIn Route to DeliveryIn Route to Pick UpIn Route for MaintenancePersonal ConveyanceOtherWhere was the Driver Headed?* Order Number* Accident Date* MM slash DD slash YYYY Accident Time* AM/PM* AMPMTime Zone Accident Occurred* ESTCSTMSTPSTAccident Location Name* Accident Location Address* City* State*- Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoZip* Fuel Spill*- Select -YesNo# of Gallons ( if yes )* Responding Agency* Officer At Scene*- Select -YesNoDepartment* Report Number* Ticket issued*- Select -YesNoUnknownTo Whom* Charge* How Many Other Vehicles Involved*- Select -012345Additional VehiclesVehicle #2Vehicle description (Make, Type, Year, Color…)*Plate Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoDriver Name* Contact NumberAddress Line 1* Address Line 2 City* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoZip* License Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoInsurance Information* Describe DamageNumber of People in the Vehicle*123456Was Anyone injured?*- Select -YesNoInjuriesWas Anyone Transported from the scene by ambulance?*- Select -YesNoIf yes what hospital? Was Vehicle Towed From Scene?*-Select -YesNoVehicle #3Vehicle description (make, type, year, color…)*Plate Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoDriver Name* Contact numberAddress Line 1* Address Line 2 City* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoZip* License Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoInsurance Information* Describe DamageNumber of People in the Vehicle*123456Was Anyone injured?*- Select -YesNoInjuriesWas Anyone Transported from the scene by ambulance?*- Select -YesNoIf yes what hospital? Was Vehicle Towed From Scene?*-Select -YesNoVehicle #4Vehicle description (Make, Type, Year, Color…)*Plate Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoDriver Name* Contact NumberAddress Line 1* Address Line 2 City* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoZip* License Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoInsurance Information* Describe DamageNumber of People in the Vehicle*123456Was Anyone injured?*- Select -YesNoInjuriesWas Anyone Transported from the scene by ambulance?*- Select -YesNoIf yes what hospital? Was Vehicle Towed From Scene?*-Select -YesNoVehicle #5Vehicle description (Make, Type, Year, Color…)*Plate Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoDriver Name* Contact NumberAddress Line 1* Address Line 2 City* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoZip* License Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoInsurance Information* Describe DamageNumber of People in the Vehicle*123456Was Anyone injured?*- select -YesNoInjuriesWas Anyone Transported from the scene by ambulance?*- Select -YesNoIf yes what hospital? Was Vehicle Towed From Scene?*-Select -YesNoVehicle #6Vehicle description (Make, Type, Year, Color…)Plate Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoDriver Name* Contact Number Contact NumberAddress Line 1* Address Line 2 City* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoZip* License Number* State*-Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaCanada - AlbertaCanada - British ColumbiaCanada - ManitobaCanada - New BrunswickCanada - NewfoundlandCanada - Northwest TerritoriesCanada - Nova ScotiaCanada - OntarioCanada - Prince Edward IslandCanada - QuebecCanada - SaskatchewanCanada - YukonPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsMexicoInsurance Information* Describe DamageNumber of People in the Vehicle*123456Was Anyone injured?*- Select -YesNoInjuriesWas Anyone Transported from the scene by ambulance?*- Select -YesNoIf yes what hospital? Was Vehicle Towed From Scene?*-Select -YesNo