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x UNIVERSITY OF MISSOURI VEHICLE ACCIDENT REPORT- 2. Information Supplied By (Driver Signature) 3. Department Name 5. Date of Accident 6. Time of Accident DRIVER INFORMATION UNIVERSITY VEHICLE OTHER VEHICLE OR PROPERTY 9. Driver's Age 14. Driver's Name 15. Driver's Age* 12. Driver's or Chauffeur's License Number 16. Driver's Address 17. Driver's Telephone* 18. Driver's or Chauffeur's License Number> 19. If driver was not the owner, give owner's name and address& Insured By (name of insurance company)4 Insurance Agent (name, address and telephone number) INJURED AREA CODE & PHONE NAME AND ADDRESS WITNESSES OR PASSENGERS ACCIDENT INFORMATION UM VEH. OTHER PED. 20. 21. 22. 23. 24. LOSS INFORMATION 28. Year, Make and Model of Car 29. License Number and State 36. Year, Make and Model of Car 37. License Number and State! 30. Vehicle Identification Number 31. 38. Describe Damage to Vehicle 32. Used with Permission 33. Describe Damage to Vehicle Please note - for items 34, 35, 39 & 40, if information is not readily available, do not delay report, simply forward repair estimates as soon as possible7 34. Name and address where vehicle was taken for repair7 39. Name and address where vehicle was taken for repair 35. Estimated Cost to Repair 40. Estimated Cost to Repair $ LIGHT (Check one)
Specify Other WEATHER ROAD CHARACTER ROAD SURFACE* Driving under the influence of intoxicants Untrained or unskilled" Abstracted-thinking of job details Hurry or Impatience! Irritated-by another driver, etc.
Distracted# Fatigue-long driving, lack of sleep 111-physical weakness
Other causes: CAUSE OF UNSAFE DRIVING ACT Other Driving too fast-or too slow Did not grant right of way Followed too closely On wrong side of road or lane Failed to give proper signal Disregarded stop sign Improper passing
Improper turn Disregarded stop and go light! Disregarded other traffic control& Improper starting from parked position Improper backing maneuver Other improper actions Seat Belts Worn? Yes - No - No improper driving or parkingj What action has or will be taken to prevent recurrence: (Attach a separate sheet if more space is needed): MoCode Supervisor's Signature Title Date% Campus Claims Coordinator's Signature
Deductibles: < $500 for liability for owned or rented and collision claims: No unsafe driving act- SUPERVISOR'S REPORT OF ACCIDENT INVESTIGATION (Check One) 1. Date Report Prepared 4. Department Telephone 7.S Place of Accident (city, state; if on a highway, give number and nearest community) 8.
Driver's Name 10. Driver's University Address 11. University Telephone 13.( Purpose for which vehicle was being used 25. 26. 27.< Was a law enforcement agency notified? If so, name of agencyW Was citation issued as a result of accident? If so, to whom issued and for what reason?Z Brief description of accident (speed, traffic, road conditions, seat belts, signals, etc.) This report is to be completed in the event any of the following vehicles are involved in an accident. (1) any University-owned vehicle; (2) any employee-owned vehicle used on official University business; and (3) any vehicle rented or leased by or for the University. This form is to be typed (original only). The Department Chairperson or Supervisor should complete the Supervisor's Report of Accident Investigation section, and forward to the Campus Claims Coordinator within 48 hours after the accident. INDICATE Use one of these outlines to sketch the scene of your accident; OUTLINE ROADWAY WITH SOLID LINES AND IDENTIFY BY ARROW ALL STREETSd $250 for comprehensive; $0 for physical damage to a commercially rented automobile (i.e. Enterprise)
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