Form Std. 270 - Vehicle Accident Report
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DISTRIBUTION: OFFICE OF RISK AND
STATE OF CALIFORNIA - DGS ORIM
THIS REPORT MUST BE MAILED WITHIN 48 HOURS AFTER ACCIDENT
ORIGINAL -
INSURANCE MANAGEMENT
VEHICLE ACCIDENT REPORT
(ACCIDENTS INVOLVING INJURY SHOULD FIRST BE CALLED OR FAXED
707 THIRD STREET, FIRST FLOOR
TO ORIM AT (916) 376-5302 - CALNET 480-5302 - FAX (916) 376-5277.)
WEST SACRAMENTO, CA 95605
STD. 270 (REV. 2/2002c)
COPY - STATE GARAGE (DGS pool vehicle only)
* CONFIDENTIAL INFORMATION *
COPY - DEPT. FILES (Dept. owned vehicles only)
ACCIDENT PREVIOUSLY REPORTED TO ORIM? (If Yes, give date)
COPY - STATE DRIVER
DO NOT RELEASE TO OTHER PARTIES WITHOUT CONSENT OF THE
YES
NO
(Dept. owned vehicles only) Page
of
OFFICE OF RISK AND INSURANCE MANAGEMENT
NAME
AGE
EMPLOYING DEPARTMENT
AGENCY BILLING CODE
OFFICE ADDRESS
DRIVER’S LICENSE NO.
ACCIDENT DATE
TIME
AGENCY DOCUMENT NO.
(Optional)
WAS VEHICLE BEING USED ON OFFICIAL
STATE BUSINESS?
YES
NO
(If NO, attach explanation)
DATE DRIVER LAST COMPLETED
Month/Year
JOB TITLE
BUSINESS TELEPHONE
STATE DEFENSIVE
NOT TAKEN
DRIVER TRAINING
VEHICLE LICENSE NUMBER
VEHICLE YEAR, MAKE, MODEL
VEHICLE OWNER
DEPT. VEHICLE NO.
(Optional)
DEPARTMENT OWNED
DGS POOL
DESCRIBE DAMAGES TO STATE VEHICLE
ESTIMATED
REPAIR COST
RENTAL
EMPLOYEE OWNED
IF DEPARTMENT OWNED OR RENTAL, ENTER OWNER’S NAME
ROAD CONDITIONS
ACCIDENT LOCATION (Address/Area)
WEATHER CONDITIONS
(City/State)
TRAFFIC CONDITIONS
(County)
HOW FAST WERE YOU DRIVING?
EST. SPEED OF OTHER CAR
NAME AND ADDRESS OF INVESTIGATING AGENCY
POLICE REPORT MADE
YES
NO
AGENCY
CHP
OTHER
DRIVER’S NAME
AGE / DOB
VEHICLE LICENSE NUMBER
VEHICLE YEAR, MAKE, MODEL
NO. OF PASSENGERS
DRIVER’S LICENSE NO.
HOME TELEPHONE
WORK TELEPHONE
REGISTERED OWNER
OWNER’S ADDRESS
HOME TELEPHONE
DRIVER’S ADDRESS (Street, City, State, Zip Code)
WORK TELEPHONE
BRIEFLY DESCRIBE DAMAGES TO OTHER VEHICLE OR PROPERTY
NAME AND ADDRESS OF OTHER PARTY’S INSURANCE
NAME
AGE
ADDRESS
HOSPITAL
NAME
AGE
ADDRESS
HOSPITAL
NAME
TELEPHONE
ADDRESS
NAME
TELEPHONE
ADDRESS
NAME
ADDRESS
NAME
ADDRESS
NAME
ADDRESS
NAME
ADDRESS
(CONTINUE ON REVERSE)
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