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 Dedicated of Greer, SCUniversal 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 Street Address*City/State*Zip Code*County*Job Title*- Select -Company DriverAgency TempIndependent ContractorOffice EmployeeNon Office EmployeeSex*- Select -MaleFemaleNumber Of Dependents*012345Start Date* 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* 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 2City*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 2City*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 2City*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 2City*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 NumberContact NumberAddress Line 1*Address Line 2City*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