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? 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) Where is vehicle normally garaged?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 vehicleInjuries:
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)? Charges filed?Glass Breakage:
Complete this section for any glass breakage to the state vehicle.Date of Report:
Date report filed.Reported By:
Person completing form.
Reported to CAPSTONE?
Was the insurance company notified?If you should have any questions regarding the completion of this form, contact Risk Management at (434) 924-3055.