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IREDELL COUNTY ACCIDENT REPORT
Name: Time of Accident
Date of Accident Department
Description of Vehicle Involved
Location of Accident
Law Enforcement Agency at the Scene
(Copy of Accident Report MUST be attar e
Was another vehicle involved? _Yes _No
Were you injured? Yes No If yes, did you receive medical treatment?
yes no1Rave you completed the required Workmens Compensation forms
anc subm t� them? Yes No
Were any of the passengers in the other vehicle injured? yes no
Were they taken to a hospital immediately following the aoidentT-- yes
no
Destination and purpose of trip
Description of Accident —
Witnesses: Name Telephone M
Address —
Name Telephone X
Address
Signed Date
IREDELL COUNTY INCIDENT REPORT
Name of Employee Date of Incident
' Department