Accident/Injury Customer Report Report Date* MM slash DD slash YYYY Date of Accident/Incident* MM slash DD slash YYYY Time of Accident/Incident* : Hours Minutes AM PM AM/PM Accident Location InformationLocation of Accident* Long-Lewis Alabaster Long-Lewis Calera Long-Lewis Corinth Long-Lewis Florence Long-Lewis Hoover Long-Lewis Muscle Shoals Long-Lewis Prattville Long-Lewis Selma Ouellette & Associates Extreme Auto Design CarQuest Description of Area Where Accident Took Place* Name of Employee Reporting Accident* First Last Phone of Employee Reporting Accident*Email of Employee Reporting Accident* Person Injured InformationName of Person Injured* First Last Phone of Person Injured*Email of Person Injured Accident/Incident Details*Hospitalization Required?* Yes No If taken to the hospital, how was the person transported? Ambulance Long-Lewis Employee Family Member/Friend Witness InformationName of Witnesses 1 First Last Phone of Witnesses 1Email of Witnesses 1 Name of Witnesses 2 First Last Phone of Witnesses 2Email of Witnesses 2 Name of Witnesses 3 First Last Phone of Witnesses 3Email of Witnesses 3 If More Than 3, Please List HereAdditional Information/DetailsUpload Photos/Supporting DocumentationAccepted file types: jpg, tiff, pdf, doc, docx, xls, xlsx, Max. file size: 16 MB.If you would like to upload photos and/or supporting documents, please do so above. Acceptable file formats are jpg, tiff, pdf, doc, docx, xls, xlsx.CAPTCHA Δ
