Neace Lukens - Truck Accident Form

Are you insured by Neace Lukens? *
YesNo

If yes, list agent name or Neace Lukens office location:

Insurance Company: *

Policy Number: *

Date Reported: *

Insured/Your Company Name: *

Contact:

Phone: (Contact)

Reported By:

Phone: (Reported By)

Check One:
Report as a claimReport as information only

Was claim called in direct to insurance company
YesNo

Claim #:

Accident Date/Time: *

DOT Reportable:
YesNo

Accident Location: (Street Address, City, State, County) *

Characters Remaining: 1000

Accident Description: (What happened - include cargo) *

Characters Remaining: 1000

Cargo Reported: (Separate claim needs to be reported. Notify Neace Lukens)

Insured Driver Name:

Owner of Vehicle:

Ticket/Citation:

Phone: (Insured Driver)

Drug Screen Date/Time:

Drug Screen Performed At:

Driver was instructed to submit to:
substance testingvoluntary testing

Vehicle Dispatched From:

To:

Vehicle/Tractor Year:

Vehicle/Tractor Make:

VIN#: (last 6 digits)

Pollution/Fuel Spill:

Damage:

Towed
YesNo

Location of Vehicle:

Phone: (Vehicle)

Name of Injured:

Type of Injury:

Fatality
YesNo

Workers Compensation report direct to: (separate claim)

Driver Name:

Ticket/Citation issued:

Owner Name:

Address: (Owner)

Phone: (Owner)

Vehicle Year:

Vehicle Make:

Damage:

Name of Injured:

Type of Injury:

Fatality
YesNo

Removed by ambulanceReceived treatment away from scene

Insurance Company:

Policy #:

Witness Name:

Phone: (Witness)

City/County/State:

Report #:

Phone: (Police)

* = required field

First Notice of Trucking Accident Information Sheet

Insured/Your Company Information

Other Person Involved

Witness

Police