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 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)? Charges filed?
Glass Breakage:Complete this section for any glass breakage to the state vehicle.
Date of Report:Date report filed.
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.