AUTOMOBILE ACCIDENT PROCEDURE
If an accident involving an owned or rented vehicle has just occurred, take any emergency actions that are necessary and follow these steps:
1. Call
911 immediately so an official accident report will be prepared. Inform 911 of serious injuries that could require emergency equipment/personnel to be dispatched to the scene.
2. Obtain the following information to complete the Automobile Accident Report.
DEPARTMENT INFORMATION
DEPARTMENT NAME: DEPARTMENT CODE (if applicable):
CONTACT PERSON (at location): PHONE: ( ) EMAIL:
ACCIDENT INFORMATION
DATE/TIME OF INCIDENT: POLICE CONTACTED? YES NO REPORT #:
LOCATION OF ACCIDENT: CITY & STATE:
DESCRIPTION OF ACCIDENT:
INSURED VEHICLE INFORMATION
DRIVER’S NAME: DRIVER’S LICENSE #:
ADDRESS: CITY & STATE:
HOME PHONE: ( ) WORK PHONE: ( )
NAME OF DRIVER’S IMMEDIATE SUPERVISOR: PHONE #: ( )
VEHICLE YEAR / MAKE / MODEL: PLATE #: VIN:
DESCRIBE DAMAGE:
OTHER VEHICLE INFORMATION #1
OTHER DRIVER’S NAME: HOME PHONE: ( ) WORK PHONE: ( )
ADDRESS: CITY & STATE:
VEHICLE YEAR / MAKE / MODEL: PLATE #: VIN:
OTHER VEHICLE INSURANCE COMPANY: POLICY #:
DESCRIBE DAMAGE:
PASSENGER NAMES:
WAS ANYONE CLAIMING INJURY / WHO: DESCRIBE INJURY COMPLAINTS:
OTHER VEHICLE INFORMATION #2
OTHER DRIVER’S NAME: HOME PHONE: ( ) WORK PHONE: ( )
ADDRESS: CITY & STATE:
VEHICLE YEAR / MAKE / MODEL: PLATE #: VIN:
OTHER VEHICLE INSURANCE COMPANY: POLICY #:
DESCRIBE DAMAGE:
PASSENGER NAMES:
WAS ANYONE CLAIMING INJURY / WHO: DESCRIBE INJURY COMPLAINTS:
PLEASE SEND COMPLETED LOSS NOTICE TO:
DANIEL HARPER / TSUS – PHONE: 512-463-6449 AND Gary Rash/Lamar - FAX: 409-880-7977
EMAIL: daniel.harper@tsus.edu; SEclaims@ajg.com; AND cheryl_kelley@ajg.com; AND riskmanagement_ehs@lamar.edu
Arthur J. Gallagher Risk Management Services, Inc.
221 W
est 6th St., Suite 1980 Austin, TX 78701 CLAIMS: (855) 497-0678 FAX (225) 292-3933
INSTITUTION NAME:
