UNIVERSITY OF VIRGINIA FINANCIAL AND ADMINISTRATIVE PROCEDURES MANUAL TITLE: COMPLETING AUTOMOBILE LOSS PROCEDURE: 7-81 NOTICE Policy Reference: VII.H.1 Form: Automobile Loss Notice Obtain Blank Forms From: Claim Packet inside each University owned vehicle -OR- University Forms Directory, (Select Risk Management under Departmental Listings), http://uvaforms.virginia.edu -OR- Automobile Loss Notification Form -OR- Office of Risk Management, P.O. Box 400205, 2400 Old Ivy Road, Suite 181, Charlottesville, VA, 22904, (434) 924-3055 Forward Completed Forms To: Office of Risk Management, P.O. Box 400205, 2400 Old Ivy Road, Suite 181 Charlottesville, VA, 22904, (434) 924-3055, FAX (982-2635) Purpose To report vehicle accidents or claims for either STATE VEHICLES OR RENTAL VEHICLES USED FOR UNIVERSITY BUSINESS. ALL ACCIDENTS INVOLVING STATE VEHICLES OR RENTAL VEHICLES USED FOR UNIVERSITY BUSINESS MUST BE REPORTED TO BOTH THE STATE POLICE AND CRAWFORD & CO. IMMEDIATELY, AND TO RISK MANAGEMENT WITHIN 24 HOURS USING THIS FORM. IMMEDIATE NOTIFICATION WITHIN 24 HOURS Crawford & Co. Office of Risk Management Call toll free # P.O. Box 400205, 1-866-219-6120 2400 Old Ivy Road, Suite 181 Agency Code: 207 Charlottesville, Virginia 22904 (434) 924-3055; FAX: 982-2635
INSTRUCTIONS FOR COMPLETING AUTO LOSS NOTICE
POLICY HOLDER: UVA and Departmental name and address. Vehicle lic. plate #
TIME AND PLACE OF ACCIDENT: Date, time, and specific address of accident.
STATE AGENCY OR COMMUNITY SERVICES BOARD as insured USE ONLY:
Make, Year, Model and VIN of vehicle.
Commonwealth of Virginia is owner. Name of driver, hire date, dept. address, date of birth, Driverís license #, Was license in effect? Business or Pleasure? Who gave permission - Supervisorís name. Description of all damages to vehicle, detailed. Estimated cost of repairs – Rough idea.
OTHER AUTO INVOLVED: Enter other vehicle involved information in this section, as well as contact information for other driver/owner and insurance information.
PASSENGERS: List passengers in state vehicle and other involved vehicle
INJURIES: List any injuries of state employee, other involved driver, and passengers.
PROPERTY DAMAGE OTHER THAN AUTO: To be completed when state vehicle causes damage to non-auto property (i.e., truck hitting overhang of building).
WITNESSES: List any witnesses to the accident.
DESCRIPTION OF ACCIDENT: Complete section as best to your ability.
Did Police Investigate Accident: Were police called?
Police Address: Which agency responded (i.e., State, UVA)?
GLASS BREAKAGE: Complete this section for any glass breakage to the state vehicle.
DO YOU THINK A CLAIM WILL BE MADE AGAINST YOU? Your opinion of whether a claim will be filed because of the accident.
DATE OF REPORT: Date report filed.
SIGNATURE: Person completing form.
If you should have any questions regarding the completion of this form, contact Risk Management at (434) 924-3055.
ISSUED BY: 07/01/99 Director of Risk Management Updated: 04/26/10 7.81.1