Collect information and complete both pages of this form immediately after an accident occurs. The original report should be hand delivered to the state agency insurance representative’s office within one business day of the accident (pending injuries). If you have any questions, please call the state agency insurance representative

Name)                                                                                              Ph # _ _                                         _ _      Created 10/2010

 

General Information:

Date of Accident:                           Time:                                      o AM o PM

Location of Accident:                                                                                                                                  

City:                                                            County:                                   State:                                       

Authority Contacted:                                                                     Report #:                                               

Responding Officer:                                                                                                                                 

List any traffic violations/citations given to any drivers:                                                                           

                                                                                                                                                                 

                                                                                                                                                                 

Weather Condition:                                      Road Condition:                                Visibility:                                

Detailed description of physical conditions at location of vehicle accident:                                                         

                                                                                                                                                                 

                                                                                                                                                                 

Detailed description of activity leading to vehicle accident (draw a diagram of what happened on the back of this page):                                                                                                                                                        

                                                                                                                                                                 

                                                                                                                                                                 

Detailed description of accident and any other factors that contributed to this accident:                         

                                                                                                                                                                 

                                                                                                                                                                 

                                                                                                                                                                 

Details of injured persons in the State agency vehicle (provide name, relationship to the state agency and injury):

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       

Witness name(s) and Phone #(s):                                                                                                              

                                                                                                                                                                 

                                                                                                                                                                 

Describe Damage to Vehicle:

Identify which parts of the vehicles came into contact with each other i.e. “My left rear bumper was hit by his right front as he tried to avoid rear ending my car”:                                                                                                                                                                                                                                                                                                                                                                                                                          

                                                                                                                                                                 

State Agency Driver Information:

Name:                                                                                 Employee ID:                                                 

Driver’s License #:                                    DL State:                      Date of Birth:                                      

Home Address:                                                                                                                                         

City:                                   State:                Zip:                  Home Phone: (       )                                       

Agency Department:                                                             Job Title:                                                      

Work Phone #: (      )                                             Supervisor:                                                                 

Purpose for using the vehicle:                                                                                                                                                                                                                                                                                                                                                                                                                                                        

State Agency Vehicle Information:

Year: ____ Make:                          Model:                                                 Dept:                                         

VIN:                                                            License Plate #:                                                                     

Describe damage to State agency vehicle (Be very specific):                                                                            
                                                                                                                                                                
                                                                                                                                                              

                                                                                                                                                                 

Other Driver Information (from accident procedure page):

Driver Name:                                             Driver Address:                                                                      

City:                       State:         Zip:                 Hm & Wk Phone #: (       )                    (       )                     

Driver DL#:                                                           DL State:                      Driver DOB:                          

Owner Name:                                            Owner Hm & Wk Phone #: (    )                 (       )                   

Insurance Company Name:                                                           Phone #: (    )                                        

Insurance Policy #:                                                                        Agent:                                                  

Were photographs of the accident taken? (Check one)     Yes      No            Any obvious prior damage?                               

Other Vehicles Involved Information:

Year: _____ Make:                        Model:                         License Plate #:                        State:                 

Please list passenger names, home & day time phone #s and any injuries:                                                                                                                                                                                                                                                                                                                                                                                          

Describe damage to other vehicle(s) (Be very specific):                                                                                                                                                                                                                                                                                                                                            

                                                                                                                                                                 

Signature of State Agency Driver       Date                        Signature of Supervisor                  Date