Form Std. 270 - Vehicle Accident Report Page 2
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2STATE OF CALIFORNIA - DGS ORIM
* CONFIDENTIAL INFORMATION *
VEHICLE ACCIDENT REPORT
DO NOT RELEASE TO OTHER PARTIES WITHOUT CONSENT OF THE
OFFICE OF RISK AND INSURANCE MANAGEMENT
STD. 270 (REV. 2/2002c) (REVERSE)
FULLY STATE HOW ACCIDENT OCCURRED (Give details, attach additional sheets if necessary)
Number State vehicle as 1,
other vehicle(s) as 2, 3, etc.
1
2
O
Show pedestrian by
Show direction of travel as follows:
Before accident
After accident
Give names or numbers of streets or roads
Indicate Points
of Compass
N. S. E. W.
DRIVER’S NAME
AGE/DOB
VEHICLE LICENSE NUMBER
VEHICLE YEAR, MAKE, MODEL
DRIVER’S LICENSE NO.
HOME TELEPHONE
WORK TELEPHONE
REGISTERED OWNER
ADDRESS (Street, City, State, Zip Code)
ADDRESS (Street, City, State, Zip Code)
HOME TELEPHONE
WORK TELEPHONE
BRIEFLY DESCRIBE DAMAGES TO OTHER VEHICLE OR PROPERTY
NAME AND ADDRESS OF OTHER PARTY’S INSURANCE CARRIER
NAME
AGE
ADDRESS
HOSPITAL
NAME
AGE
ADDRESS
HOSPITAL
NAME
ADDRESS
NAME
ADDRESS
Type Name and Title of Reviewing Officer
The answers in this report contain a true and full account of the accident, and the vehicle was being operated on official business
of the state at the time of the accident. (The reviewing officer is to explain any exception.) Attach extra pages as necessary.
Employee Signature and Date
Reviewing Officer Signature (Supervisor or Safety Coordinator)
Telephone Number of Reviewing Officer
@
@
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