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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.

Reported By:

Person completing form.

If you should have any questions regarding the completion of this form, contact Risk Management at (434) 924-3055.