Accident Report

⚠️

Accident Protocol

Notify Dispatch immediately (470-713-0953) Collect Photo & Video documentation Complete detailed written statement File LMET Report (1-800-942-3300) If medical attention is needed, contact Dispatch FIRST for guidance. I have read and agree to the Affidavit below.

AFFIDAVIT:

I hereby declare that the information I am about to provide regarding this incident is true, accurate, and complete to the best of my knowledge.

All accident and/or workplace incidents are required to be completed and submitted within 24 hours of the event.

DAs are permitted to be seen by an authorized panel of physicians only. Note that DAs will also be required to take a drug test upon arrival.

2. Incident Details

Incident Type

Street Address / House # (Auto-detected or enter manually)

City

State

Zip

Location (Auto-Detected)

Lat: ... Lng: ...

Fetching Weather...

Detailed Statement (Max 500)

0 / 500

Police Report # (Required)

LMET Case # (Required)
📞 Call 1-800-942-3300 to file

4. Driver Signature

Sign Below

Email for Copy of Panel of Physicians *Required

This report was completed by a Supervisor / Manager on behalf of the driver.

Accident Report

1. Driver & Vehicle

2. Incident Details

3. Evidence (Min 3 Photos)

4. Driver Signature