Form Rm2013 - Driver'S Report Of Vehicle Accident Form
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1 UT VEHICLE NO. _______
DRIVER’S REPORT
OF
VEHICLE ACCIDENT
UNIVERSITY OF TENNESSEE
INSTRUCTIONS: Report every accident, damage or theft immediately after occurrence. Forward report immediately to:
Your Campus Transportation Services
UT DRIVER: NAME____________________________________ DATE OF BIRTH: ____________________
DRIVER’S LICENSE NUMBER: ________________________ ISSUED STATE: ____________ EXPIRATION: _______
HOME ADDRESS: _____________________________________________________________________________
(STREET, CITY, STATE AND ZIP CODE)
DEPARTMENT: _______________________________ SUPERVISOR: __________________________________
CAMPUS ADDRESS: __________________________________ PHONE: _______________________________
UT VEHICLE LICENSE NUMBER: ____________ VEHICLE: CAR ____ TRUCK_____ VAN_____ OTHER _____
MAKE: __________________________
MODEL: _________________
PARTS OF UT VEHICLE DAMAGED: _______________________________________________________________
ACCIDENT: DATE OF ACCIDENT: ________________________ TIME: ___________________ AM _______ PM ________
PLACE OF ACCIDENT: ________________________________ CITY: ___________________ STATE: _______
(STREET OR HIGHWAY)
INVESTIGATED BY: ________________________________________________________________________
(AGENCY: i.e., UTPD, Local PD, County PD, State PD)
ACCIDENT REPORT NUMBER (If Available): _____________________________________________________
OTHER VEHICLE AND DAMAGE TO PROPERTY OF OTHERS:
KIND OF PROPERTY AND EXTENT OF DAMAGE: ____________________________________________________
VEHICLE: MAKE: _____________________ MODEL: _______________________ YEAR: ______________
DRIVER OF DAMAGED VEHICLE: _______________________________ DATE OF BIRTH: ____________________
DRIVER’S LICENSE NUMBER: ________________________ ISSUED STATE: ____________ EXPIRATION: _______
HOME ADDRESS OF DRIVER: ___________________________________________________________________
(STREET, CITY, STATE AND ZIP)
OWNER OF DAMAGED VEHICLE (IF DIFFERENT FROM DRIVER): _______________________________________
HOME ADDRESS OF OWNER: __________________________________________________________________
(STREET, CITY, STATE AND ZIP)
VEHICLE INSURED: YES______ NO_______ IF YES, NAME OF INSURER: ______________________________
INSURANCE POLICY NUMBER: _________________________________ AGENT: _________________________
ADDRESS OF AGENT: ________________________________________________________________________
(STREET, CITY, STATE AND ZIP)
WHERE CAN PROPERTY BE SEEN: ______________________________________________________________
DESCRIPTION OF HOW ACCIDENT OCCURRED: _________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
WITNESSES: NAME: _______________________________________________________________________________
HOME ADDRESS: _______________________________________________________________________
NAME: _______________________________________________________________________________
HOME ADDRESS: _______________________________________________________________________
ADDITIONAL DOCUMENTATION ATTACHED: YES ________________
NO __________________
RM2013
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