Accident Report for FLEET Ambulances - DOC by mek10591

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									                                                                                                         MPI Claim Number                       Unit Number

Ambulance Accident Report
                                                                                                         Date of Accident                       Location

If you’re in an accident . . .

1. Call Police under the following conditions:                                            3. Call MPI to open a claim. Record your claim number.
         A person is injured.                                                            4. If your ambulance is managed by VEMA:
         There is more than $1,000 damage to the vehicle(s).                                   Call VEMA at 1-800-363-6693 to report your accident.
         Your vehicle has been vandalized or subject to a hit and run or theft.                Send a copy of this form to VEMA at 626 Henry Ave., Winnipeg, Manitoba
                                                                                                R3A 1P7 or fax: 204-957-1109.
         The other driver is uninsured or driving with a suspended license.
                                                                                          5. If your ambulance is not managed by VEMA:
         The other driver is impaired.
2. If someone is injured, call Manitoba Health, EMS immediately.                                Send a copy of this form to Manitoba Health, EMS at 334 1st St SW,
                                                                                                Minnedosa, Manitoba R0J 1E0 or fax: 204-867-3931.

A.       RHA
RHA                                                                                       EMS Station



Address


General Phone                                                Fax                                                        E-mail



B.       Ambulance
VEMA Unit Number                                             License Plate Number                                       License Expiry Date (if not a VEMA ambulance)



C.       Driver
Name                                                         Driver’s License Number                                    Driver’s License Expiry Date



Day Phone                                    Evening Phone                                Fax                                          E-mail



D.       Other Ambulance Occupants – Total Number of Occupants: ____ (not including driver)
         (please attach a separate sheet if more than one occupant was involved)

Occupant #1
Name                                                         Address



Day Phone                                    Evening Phone                                Fax                                          E-mail



E.       Other Vehicles and Drivers (if any) – Total Number of Vehicles Involved: ____ (including ambulance)
Vehicle #1 (please attach a separate sheet if more than two vehicles were involved)
License Plate Number                                         Province/State of Plate                                    License Expiry Date



If Not Manitoba plates—Name of Insurance Company             If Not Manitoba plates—Policy Number                       If Not Manitoba plates—Name of Agent and Address


Make (Year and Make)                                                                      Model (Body Type: Sedan, Mini Van, etc.)



Driver’s Name                                                Driver’s License Number                                    Driver’s License Expiry Date



Address



Day Phone                                    Evening Phone                                Fax                                          E-mail


Vehicle Owner’s Name (if not Driver)                         Address



Day Phone                                    Evening Phone                                Fax                                          E-mail
F.     The Accident
Date                                          Time (AM/PM)                                  Location                              Light Conditions (Dawn, Day, Dusk, Dark)


Weather at Time of Accident                                  Type of Road Surface                                Road Condition



Name of Witnesses (other than occupants)                     Witness Phone                                       Witness Address


Had You Consumed any Alcohol?                                If so, How Much                                     When
 Yes        No

Did the Other Driver Appear to Have Been Drinking?           Give any Details
 Yes        No

Direction of Ambulance                        On What Road?                                 What Side of Road?                    Speed



Direction of Other Vehicle                    On What Road?                                 What Side of Road?                    Speed


What Traffic Signals Were Present?


Did you Give A Warning Signal?                               What Kind?                                          Which Lights Did You Have On (if any)?
 Yes        No

Did the Other Driver Give A Warning Signal?                  What Kind?                                          Did the Other Driver Have their Headlights On?
 Yes        No                                                                                                  Yes        No

Has the Accident been Reported to Police?                    Did Police Attend the Scene of the Accident?        Name of Police Force
 Yes        No                                              Yes         No

Police Officer’s Name                                        Police Phone                                        Police File Number


Have the Police Charged Anyone?                              Name of Person Charged                              Nature of Charge
 Yes        No


G.     Injuries and Damage (please attach a separate sheet if you require more room.)
Nature of Damage to other Vehicles



Nature of Injuries to Drivers or Occupants



Nature of Damage to Ambulance



H.     Driver’s Detailed Description of How Accident, Loss or Mechanical Damage Occurred




Who Do You Think Was to Blame?                                                              Why?



Driver Signature                                                                            Date




If helpful, illustrate the accident at right. Be sure to note:
                                                                                                                           
    The name of all streets,
    Course of all cars involved, and
                                                                                                                           N
    Position of vehicles at instant of accident.




626 Henry Avenue, Winnipeg, Manitoba R3A 1P7
Phone: 1-800-363-6693      Fax: 204-957-1109
09

								
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