CAR ACCIDENT REPORT FORM

Document Sample
CAR ACCIDENT REPORT FORM Powered By Docstoc
					Catholic Charities, Diocese of Joliet

Administrative Procedure

Title: Procedure Number: Date Approved: Procedure:

CAR ACCIDENT REPORT FORM FF 3.02 November 12, 1997; Revised 3/6/03; Reviewed 10/12/06; Revised 08/27/08

In the event one of the agency vehicles is involved in a car accident, the enclosed form should be completed the same day as the accident. The police should be contacted at the time of any accident so a Police Report is completed. A copy of the Police Report as well as the Catholic Charities Accident Report should be faxed to the Building Manager at Catholic Charities the same day of the accident. This procedure will facilitate filing the insurance claim. Catholic Charities Attn: Building Manager Fax: 815/723-3402 Phone: 815/724-1145

COA: ASE 6

Catholic Charities, Diocese of Joliet Accident Report This report should be completed and signed by the staff person involved in the accident as well as by the immediate supervisor. Completed accident report as well as a copy of the Police Report should then be faxed to the Building Manager at Catholic Charities, 815-723-3402 on the same day of the accident. Driver (Staff Person): Name: _________________________________________________________________ Address: _______________________________________________________________ Home Phone: _________________________ Office Phone: _______________________ Drivers License #: ___________________________ Date of Birth: _________________ Vehicle Year: ________ Make: _________________ Model: _____________________ VIN #: _______________________________ License Plate #: _____________________ Date of Accident: __________________ Time of Accident: _______________________ Witnesses: (Passengers, bystanders, etc.) Name:__________________________________________________________________ Address: ________________________________________________________________ Phone #: ___________________ Other Party’s Information: Name: __________________________________________________________________ Address: _______________________________________________________________ Home Phone: ___________________________ Work Phone: _____________________ License Plate #: ___________________ Drivers License #:________________________ Insurance Company (Name and Phone Number) ________________________________________________________________________

Revised 8/27/08

COA: ASE 6

Catholic Charities, Diocese of Joliet Accident Report

Was anyone injured?

Yes

No

If yes, please explain: (passenger, driver, etc) ___________________________________ _______________________________________________________________________ Brief description of the accident: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

_____________________ Staff

____________________ Program

_______________ Date

_____________________ Supervisor

_____________________ Date

COA: ASE 6