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-
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
Complete the items on the form as follows:
DATE REPORTED: Enter date reported to Insurer. Use
mm/dd/yy format.
DATE AND TIME OF LOSS: Enter date and time accident occurred.
DRIVER'S SUPERVISOR'S NAME: Enter name of person driver reports to.
NAME AND ADDRESS OF DEPARTMENT AT UNIVERSITY OF VIRGINIA: Enter
department name and address.
AGENCY NUMBER: Should be prefilled with 207. 207 is to be used
for all University of Virginia, University of Virginia Medical
Center, and University of Virginia's College at Wise vehicle
claims.
DRIVER'S SUPERVISOR'S PHONE #: Enter the phone number of the person the driver reports to.
CLAIM NUMBER: If Crawford and Company has provided you with a claim number, enter it here.
Otherwise, leave blank.
AGENCY PHONE AND FAX: List phone and fax numbers of contact person
handling this matter for your department.
AGENCY CONTACT: List name of contact person handling this matter
for your department.
LOCATION OF ACCIDENT: Enter location where accident occurred.
POLICE NOTIFIED: Yes or No.
DEPARTMENT: Enter name of law enforcement office notified, i.e.,
State, City, County or other.
OFFICER-OFFICER PHONE: Enter law enforcement officer's name and
phone number.
CHARGES/VIOLATIONS: List SD (State Vehicle Driver) or
CD (Claimant Vehicle Driver) and what the person was charged
with, i.e., CD- Failure to yield.
ACCIDENT DESCRIPTION: Describe the accident exactly as it happened.
STATE INFORMATION: Enter all information that applies to the vehicle being
used for State business. COMPLETE ALL BLOCKS.
CLAIMANT INFORMATION: Complete all blocks in this section related
to the other property damaged or involved in the accident/incident.
COMPLETE ALL BLOCKS.
WITNESS NAME and ADDRESS and PHONE: Provide any information available for
witnesses to the accident or witnesses to statements.
REMARKS: Provide date, time, and person contacted at Crawford & Co.
Provide other pertinent details as necessary.
REPORTED BY-SIGNATURE-PHONE: Enter name of person reporting accident,
signature of person completing form, and telephone number.
ISSUED BY: 07/01/99
Director of Risk Management Updated: 04/21/08
7.81.1