Owner: Office of Property & Liability Risk Management
Completing Automobile Loss Notice
To report vehicle accidents or claims for either state vehicles or rental vehicles used for University business
System References [Top]
Office of Property & Liability Risk Management
2400 Old Ivy Rd., Suite 181
Charlottesville, VA 22904
Procedure Steps [Top]
INSTRUCTIONS FOR COMPLETING AUTO LOSS NOTICE
TIME AND PLACE OF ACCIDENT: Date, time, and specific address of accident.
ABOUT YOUR AUTO:
Make, Year, Model, VIN of vehicle, License Plate #
Name of driver, driverÕs home address
DriverÕs phone number and hire date. Dept., SupervisorÕs name, Sup. Phone number DriverÕs date of birth, DriverÕs lic. # was it in effect?, DriverÕs title
Where were you going when accident happened? Where were you coming from?
Business or Pleasure? Who gave permission - SupervisorÕs name, & title, Purpose of use Description of all damages to vehicle, detailed.
Where is the vehicle now? (Repair shop, dept.?) 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.
WITNESSES: List any witnesses to the accident.
PROPERTY DAMAGE OTHER THAN AUTO: To be completed when state vehicle causes damage to non-auto property (i.e., truck hitting overhang of building).
DESCRIPTION OF ACCIDENT: Complete section to the best of your ability.
Did Police Investigate Accident: Were police called?
Police Agency: Which agency responded (i.e., State, UVA, County)?
GLASS BREAKAGE: Complete this section for any glass breakage to the state vehicle.
DATE OF REPORT: Date report filed.
REPORTED BY: Person completing form.
If you should have any questions regarding the completion of this form, contact Property & Liability Risk Management at (434) 924-3055.
End of Activity
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