UNIVERSITY OF HOUSTON-VICTORIA - ACCIDENT CHECKLIST

This must be kept in all University of Houston-Victoria owned or leased vehicles. All the information indicated must be gathered in accidents and reported to Business Services within 24 hours of incident for insurance claims and other records.

Driver of University Vehicle/License No.__________________________________________________________________________________________

Driver of Other Vehicle/License No.______________________________________________________________________________________________

UHV Vehicle Description _______________________________________Vehicle No:______________________________________________________



Other Driver’s Address:________________________________________________________________________________________________________

Owner of Other Vehicle/License No. (if different from driver)___________________________________________________________________________

Name of Other Driver’s Insurance Company________________________________________________________________________________________

Make_______________
          (Ford/Chevrolet)

Vid:____________________________
                 (Vehicle Identification Number)

Accident Location____________________________________________________________________________________________________________

Accident Date and Time________________________________________________________________________________________________________

Conditions of the road, weather, lighting__________________________________________________________________________________________



Names and addresses of all persons involved in the accident, whether injured or not_________________________________________________________

1. ______________________________________________________ 		__________________________________________________________

2.______________________________________________________ 		__________________________________________________________



Names and addresses of witnesses and the license numbers of the first vehicles on the scene (use back if necessary) 

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________



A statement by the university driver as to how the accident happened (Use back if necessary):

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________



A description of the apparent damages to the University vehicle, cargo, and other property:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________



Name, agency, department (e.g. Victoria Police Department, Victoria Sheriff, etc.), and badge number of the investigating police officer

________________________________________________________________________________________________________________________

Case #_______________________