Instructions for Completing Automobile 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, driver’s home address, Driver’s phone number and hire date. Dept, Supervisor’s name, Sup. Phone number, Driver’s date of birth, Driver’s license #, Was license in effect? Driver's title, Where were you going when accident happened? Where were you coming from? Business or Pleasure? Who gave permission - Supervisor’s name, & title, purpose of use, description of all damages to vehicle, detailed. Where is the vehicle now ( repair shop, parking lot?) 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.
Witness: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 Address: Which agency responded (i.e., State, U.Va., County)?
Glass Breakage:Complete this section for any glass breakage to the state vehicle.
Date of Report:Date report filed.
Driver must print name and sign form.
If you should have any questions regarding the completion of this form, contact Property & Liability Risk Management at (434) 924-3055.