Is anyone hurt? Call 911 first. Fill this out once everyone is safe.
No injuries? Call non-emergency dispatch for a police report: Farmington, NM · (505) 334-6622 Durango, CO · (970) 385-2900
What to do at the scene
  1. Stop, turn on your hazards, and move the truck out of traffic if it can be moved safely.
  2. Call 911 if anyone is hurt, vehicles are blocking the road, or the other driver leaves. Otherwise call non-emergency dispatch: Farmington, NM (505) 334-6622, or Durango, CO (970) 385-2900.
  3. Call your supervisor, Fleet, and HR before you leave the scene.
  4. Trade name, driver's license, plate, and insurance details with the other driver. M&R's insurance info is in the box below.
  5. Take the photos listed in the Photos section below.
  6. Do not admit fault or argue about who caused it. Give the facts to police, your supervisor, Fleet and HR only.
  7. Submit this report as soon as possible after the incident.
M&R insurance info for the other driver or the officer
Insurance company
Acuity, A Mutual Insurance Company
Policy number
FG2367
Company number
14184
Insurance agency
Kysar Millennium Leavitt Insurance Agency, Inc.
300 W Arrington, Suite 100
Farmington, NM 87401

The insurance card in your truck has the same information.

You and your truck

When and where

Seat belt on?
Was your phone in use?

What happened

In your own words, in the order it happened. Stick to what you saw and did. Do not guess at fault.

Your description * (say it or type it)

Tap Record, say what happened, then tap Stop. Up to 5 minutes.

Other vehicles

Was another vehicle involved? *

Injuries

Was anyone hurt, including you? *

Damage

Is your truck drivable?

Police and witnesses

Were police called? *

Witnesses

Anyone who saw it happen and was not in either vehicle.

Photos

  • All four sides of your truck, and close-ups of the damage
  • Each other vehicle, its damage, and its license plate
  • The other driver's license and insurance card
  • The whole scene, skid marks, debris, and nearby signs or signals
  • A sketch of what happened, if it helps

Sign and submit

Sign with your finger *
Your answers are saved on this phone until you submit.