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Procedure: 7-81

Effective: 7/1/2014

Owner: Office of Property & Liability Risk Management

Latest Revision:

Completing Automobile Loss Notice

Procedure Steps

Scope | System References | Policy | Responsibility | Distribution | Ownership

Scope

To report vehicle accidents or claims for either state vehicles or rental vehicles used for University business

System References [Top]

Claim information inside each University owned vehicle

University Forms Directory

Auto Loss Notice

Office of Property & Liability Risk Management

2400 Old Ivy Rd., Suite 181

Charlottesville, VA 22904

(434) 924-3055

http://www.virginia.edu/riskmanagement/

Policy [Top]

PRM-014 Use and Management of University-Owned Vehicles

FIN 006 Insurance Coverage

Responsibility [Top]

All accidents involving state vehicles or rental vehicles used for University business must be reported to both the State Police and the Office of Property & Liability Risk Management.

Distribution [Top]

All Departments

Ownership [Top]

Office of Property & Liability Risk Management

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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