Accident Report Form

This report was created using information from FedEx form OP-135 Rev 2/2022 to make it easier to collect post-accident information for FedEx Ground Contractors.

This is a lengthy form. To help you, you may save your progress and come back at a later time when you have all of the required information.

"*" indicates required fields

1Basic Info

2Vehicle

3Second Vehicle

4Second Driver

5Second Vehicle Passengers

6Third Vehicle

7Third Driver

8Third Vehicle Passengers

9Law Enforcement

10Witnesses

11Injuries

12Details

Your Name*

First Last

Your Email*

Date of Accident*

MM slash DD slash YYYY

Time of Accident*

Hours

Minutes

AM/PM

Was another vehicle involved?

Yes, 1 other vehicle

Yes, 2 other vehicles

Yes, 3 or more other vehicles

Was anyone injured?

Yes

Was law enforcement involved?

Yes

Were there any witnesses?

Yes

If you have been involved in an accident involving 3 or more other vehicles, please contact Linehaul Central directly at (708) 5-SAFETY or safety@linehaulcentral.com

Driver Information

Driver Name

First Last

FedEx ID

Phone

Vehicle Information

Truck Unit Number

VIN

Year

Make

Model

Vehicle Type

FXG Owned

Service Provider Owned/Leased

Rental

Trailer Number(s)

Dolly Number(s)

Is the VEDR camera still in the vehicle?

Yes

If NO, who has possession of the VEDR Camera?

Adjuster

Law Enforcement

Authorized Officer

Driver

Station Management

Safety

Unknown

Second Vehicle Information

Vehicle Owner's Name

First Last

Owner's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner's Telephone Number

License Plate Number

Vehicle Year

Vehicle Make

Vehicle Model

Insurance Company Name

Insurance Policy Number

Was there a driver in the second vehicle?

Yes

Were there passengers in the second vehicle?

Yes

Second Vehicle Information — Driver

Driver Name

First Last

Driver Date of Birth

MM slash DD slash YYYY

Driver Age

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Driver License Number

Issuing State

Second Vehicle Information — Passenger(s)

How Many Passengers in Vehicle Number 2?

Include for All Passengers:

Name; Date of Birth and Age; Address; Telephone Number; Email Address

Third Vehicle Information

Vehicle Owner's Name

First Last

Owner's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner's Telephone Number

License Plate Number

Vehicle Year

Vehicle Make

Vehicle Model

Insurance Company

Insurance Policy Number

Was there a driver in the third vehicle?

Yes

Were there passengers in the third vehicle?

Yes

Third Vehicle Information — Driver

Driver Name

First Last

Driver Date of Birth

MM slash DD slash YYYY

Driver Age

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Driver License Number

Issuing State

Third Vehicle Information — Passenger(s)

How Many Passengers in Vehicle Number 3?

Include for all passengers:

Name; Date of Birth and Age; Address; Telephone Number; Email Address

Law Enforcement Information

Include the information for all responsible officers at the scene.

Department (Local/County/State); Name of Officer; Badge Number; Post; Telephone Number; Email Address

Upload a Photo of the Officer's Business Card

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 25 MB.

Upload a Copy of Any Violations/Tickets

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 25 MB.

Witness Information

Include this information for all Witnesses:

Name; Approximate Age; Address; Telephone Number; Email Address

Injury Information

Include information for any person(s) injured

Name; Approximate Age; Address; Telephone Number; Email Address

Location Information

Speed Limit at Accident Location

Please enter a number less than or equal to 100.

How Many Lanes in the Roadway?

Please enter a number less than or equal to 50.

Description of Highway

(Check All that Apply)

Straight

Curve

Level

Grade

Hillcrest

Dry

Wet

Mud

Ice

Snow

Oil

Check All that Apply to the Roadway

Marked

Divided

One-Way

Two-Way

Check All that Apply for Visibility

Dawn

Day

Dusk

Dark

Artificial

Accident Details

Please Describe the Accident

In your own words, describe what happened in the accident.

Describe Damage to Property OTHER THAN a Motor Vehicle

Guardrails, bridges, signs, etc. Include this information if you can: Property Owner’s Name; Property Owner’s Address; Property Owner’s Telephone Number

Location of Accident Documents

Add the web address for any cloud storage locations for documents, photos, videos, etc.

Upload Weather Screenshot

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

Upload a Drawing or Diagram of the Accident Scene

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

Upload Screenshot of Map Location

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

Upload a Copy of the Driver's Log(s)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

Comments

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