School Bus Accident Investigation Form and Seating Chart

Accident Investigation Form andSeating ChartDESCRIBE WHAT PEDESTRIAN WAS DOING A TIME OF ACCIDENT (Crossingintersection with signal, against signal, diagonally, in roadway, playing,walking):DATE OF ACCIDENT:TIME OF ACCIDENT:SECTION IV – ACCIDENT TIME AND LOCATIONPLACE OF ACCIDENT (street address, city, state, zip; nearest landmark, distance nearestintersection. Kind of locality (industrial, residential, rural, etc.) Road description.):AMPMINDICATE ON THIS DIAGRAM HOW THE ACCIDENT HAPPENEDUse one of theseoutlines to sketch thescene. Write in street orhighway names ornumbers. Vehicle 1 isyour company’s vehicle.Show NORTH witharrow.DESCRIBE WHAT HAPPENED (Refer to vehicles as 1, 2 and 3 with 1 being you company’s vehicle. Please includeinformation on posted speed limit, approximate speed of the vehicles, road conditions, weather conditions, drivervisibility, condition of accident vehicles, traffic controls (warning light, stop signals, etc.) condition of light and driveactions (making U-turn, passing, stopped in traffic, etc.)):SB 2 (9/13) © 2013 Nationwide Mutual Insurance Company Page 2 of 7All Rights Reserved

Accident Investigation Form andSeating ChartSECTION V – WITNESS/PASSENGERNAME: WORK TELEPHONE: HOME TELEPHONE:BUSINESS ADDRESS:HOME ADDRESS:BUSINESS ADDRESS:HOME ADDRESS:SECTION VI – PROPERTY DAMAGENAME OF OWNER: WORK TELPHONE: HOME TELEPHONE:BUSINESS ADDRESS:HOME ADDRESS:NAME OF INSURANCE COMPANY: TELEPHONE NUMBER: POLICY NUMBER:ITEM DAMAGED: LOCATION OF DAMAGED ITEM: ESTIMATED COSTS:SECTION VII – POLICE INFORMATIONNAME OF POLICE OFFICER: BADGE NUMBER: TELEPHONE NUMBER:DEPARTMENT:PERSON CHARGED WITHACCIDENT:VIOLATIONS:SECTION IX – ACCIDENT INVESTIGATION DATADID THE INVESTIGATION DISCOLOSE CONFLICTING INFORMATION: YES NOIF YES, EXPLAIN BELOW:PERSONS INTERVIEWEDNAME: DATE: NAME: DATE:NAME: DATE: NAME: DATE:NAME: DATE: NAME: DATE:NAME: DATE: NAME: DATE:SB 2 (9/13) © 2013 Nationwide Mutual Insurance Company Page 3 of 7All Rights Reserved

Accident Investigation Form andSeating ChartLIST ALL ATTACHMENTS BELOW:SECTION XII – ATTACHMENTSREVIEWING OFFICIALS COMMENTS:SECTION XIII – COMMENTS/APPROVALACCIDENT INVESTIGATORSIGNATURE AND DATE:NAME – PRINTED:TITLE:OFFICE:OFFICE TELEPHONE NUMBER:ACCIDENT REVIEWING OFFICIALSIGNATURE AND DATE:NAME – PRINTED:TITLE:OFFICE:OFFICE TELLPHONE NUMBER:ATTACH PHOTOS AS NECESSARYSB 2 (9/13) © 2013 Nationwide Mutual Insurance Company Page 4 of 7All Rights Reserved

Accident Investigation Form andSeating ChartNAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:SCHOOL BUS SEATING CHARTNAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:SB 2 (9/13) © 2013 Nationwide Mutual Insurance Company Page 5 of 7All Rights Reserved

Accident Investigation Form andSeating ChartNAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:SCHOOL BUS SEATING CHARTNAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:SB 2 (9/13) © 2013 Nationwide Mutual Insurance Company Page 6 of 7All Rights Reserved

Accident Investigation Form andSeating ChartNAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:SCHOOL BUS SEATING CHARTNAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:NAME:PHONE NUMBER:ADDRESS:This information may not address all hazardous conditions at your location and does not warrant workplace safety orcompliance with federal, state or local laws.SB 2 (9/13) © 2013 Nationwide Mutual Insurance Company Page 7 of 7All Rights Reserved