24/7 Emergency Service
Serving Lake, Sumter, Citrus, Marion, Hernando, Levy, and Alachua.

Employee Car Accident Form

MM slash DD slash YYYY
Are you filling out this form out for yourself?(Required)
MM slash DD slash YYYY
Time of Accident(Required)
Were the police called?(Required)
Have you informed your supervisor of the accident?(Required)
Did you have any passengers?(Required)
Did you receive a citation?(Required)
Provide as much detail as possible, including dates, times, names, etc. Be very specific.
Do you require medical attention?(Required)
Drop files here or
Max. file size: 5 MB, Max. files: 5.