FM-16 N.C Department of Administration
(REV 4-03)
Motor Fleet Management Division
VEHICLE ACCIDENT REPORT
This report must be filed regardless of amount of damages
Driver's License #
Traveler’s Insurance Claim #
1. DRIVER & STATE OWNED VEHICLE
Name: Department: Office Phone:
Home Address: Vehicle Color:
Vehicle No:
Year: Make: Serial No: License Plate No:
Describe damage to state owned vehicle:
II. SECOND PARTY & NON-STATE VEHICLE
Owner: Driver (if not owner:
Address:
Address:
Driver License No: Home Phone: Vehicle Color: Home Phone:
Type Vehicle: Year: Make: License No: Insurance Co: Policy No:
Describe damage to non-state vehicle:
III. INJURED:
Name: Name:
Address: Address:
Home Phone: Home Phone:
Describe Injuries: Describe Injuries:
IV. ACCIDENT
Location: (Street(s), City County:
Date: Time: Investigating Officer:
Describe accident in detail (use back of form to continue/diagram accident):
V. WITNESSES
Name: Name:
Address: Address:
Return to:
Worker's Compensation Administrator: Lisa Wilcox
Signature, state owned vehicle driver:
Date:
