Version3.0,April2014 Page1of2
University of Guelph
Licensed Vehicle Incident Report
Insured
Registered Owner: ___________
______________________________________________________ Phone: _____________________________
Lessee: __________________________________________________________________________ Phone: _____________________________
Address: _____________________________________________________________________________________________________________
Drive
r
Name: _________________
________________________ Driver’s Age ____ Driver’s License No. ____________________________________
Vehicle was used for: Business ___ Pleasure ___
Your Vehicle
Year: _________ Make: ______________________ Model: _____________________________________ U of G Vehicle ID No.____________
Serial No. (VIN) __________________________________________________ License Plate No. _____________________________________
Describe Damage: ____________________________________________________________________ Estimate $ _______________________
Where is vehicle now? __________________________________________________________________________________________________
Time and Place
Date of Accident: ________________ Time: ____
_______ Town/City: ______________________________ Province: ____________________
Place: _______________________________________________________________________________________________________________
Damage to Property of Others
Owner: _________________________________________ Address: _____________________________________________________________
Driver: _________________________________________ Address: _____________________________________________________________
Vehicle Make: ___________________________________ Year: ________________ Model __________________________________________
Driver’s License No. _______________________________________________ Phone: ______________________________________________
Describe Damage _______________________________________________________________________________ Estimate $ _____________
Persons Injured
Names:
Addresses: Ages:
_________________________________________ ________________________________________________________________ ________
_________________________________________ ________________________________________________________________ ________
_________________________________________ ________________________________________________________________ ________
Police
Y
es ___ No ___ Name of Officer: _________________________________ Badge No. _________ Station: ____________________________
Independent Witnesses
Names:
Addresses: Ages:
_________________________________________ ________________________________________________________________ ________
_________________________________________ ________________________________________________________________ ________
_________________________________________ ________________________________________________________________ ________
Adjuste
r
Name of Adjusting Company: ___________________________________________________________ Date: __________________________
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Version3.0,April2014 Page2of2
University of Guelph
Licensed Vehicle Incident Report
Description of Incident:
Driver’s Signature: __________________________________________ Date: ________________________
(mm/dd/yyyy)
Save and print this form. Obtain all required signatures and email the completed form to The University of
Guelph, Associate Director for Risk and Insurance at sasha@uoguelph.ca, and the Manager, Transportation
Services at paulcook@uoguelph.ca.
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