Employee Van Damage Report

EMPLOYEE VAN DAMAGE REPORT

Purpose: This form documents damage to a company van and initiates administrative, safety and insurance processes. Complete this form truthfully and submit to Human Resources and Fleet Services within 24 hours of the incident. Incomplete or false statements may result in disciplinary action.

Personal Information

Position Information

Vehicle Information

Van Unit #:    License plate:    VIN:

Odometer reading at time of incident:    Last serviced:

Incident Details

Date of incident:    Time:    Location:

Weather/road conditions:

Damage Location (check all that apply)

Witnesses

Immediate Actions & Attachments

Damage Estimate & Insurance

Insurance claim filed: Yes    Claim number:    Insurer notified date:

Supervisor Investigation (to be completed by supervisor)

Recommended Disciplinary Action

Employment History (required)

Education

References (3 professional)

Legal Notices, Authorizations & Certifications

Reporting requirement: Employee certifies that the information provided is truthful and complete to the best of their knowledge. Employee acknowledges the duty to report vehicle damage immediately and understands failure to timely report may result in corrective action.

Liability and insurance: Submission of this report does not constitute admission of fault. The company reserves the right to pursue insurance claims, subrogation, or recovery from responsible third parties or employees as permitted by policy and law. Employee may be held financially responsible for damage caused by willful misconduct or violation of company policy.

Cooperation: Employee authorizes the company to investigate the incident, including inspection of vehicle, review of telematics/GPS and other records, and to obtain statements from witnesses. Employee must cooperate fully with the investigation.

At-Will Employment: Nothing in this form alters the at-will nature of employment where applicable. Either the employee or the company may terminate employment at any time, with or without cause, subject to applicable law.

Equal Opportunity: The company provides equal employment opportunity and does not discriminate in employment on any protected basis. This incident report will be handled in a manner consistent with equal employment practices.

Authorization to contact previous employers and background checks: Employee authorizes the company to contact previous employers and to conduct background checks or driving record checks if relevant to the investigation. Employee consents to release of driver history and records as permitted by law.

Acknowledgment and Signature

By signing below, I certify under penalty of company disciplinary policy that the statements made in this report are true and accurate. I understand that disciplinary action, including financial responsibility for damage, may result if the investigation determines policy violations or intentional misconduct.

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