Fillable Form 10.: ACCIDENT REPORT LOUISIANA STATE DRIVER SAFETY (McNeese State University)

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Form 10.: ACCIDENT REPORT LOUISIANA STATE DRIVER SAFETY (McNeese State University)

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DA 2041
Rev. 12/98
ACCIDENT REPORT
LOUISIANA STATE DRIVER SAFETY PROGRAM
Submit report to ORM
within 48 hours of accident
SUPERVISOR
TO COMPLETE
FIRST 4 ITEMS
1. Agency Name 2. Person to Contact 3. Phone 4. Loc. Code
5. State Vehicle Driver’s Name 6. Personnel Number 7. Date of Accident 8. Time of Accident
AM
PM
9. Exact Location of Accident (Use street markers, mileage markers, etc., to pinpoint location)
10.
DESCRIBE
HOW ACC.
HAPPENED
11.Seat Belt in Use
Yes No
STATE VEHICLE INFORMATION
If other then vehicle damage, fill in as much as possible under “Other Vehicle” section substituting property owner information for vehicle driver.
12. State Vehicle Driver’s Address (Street No) City State Zip Code 13. Home Phone 14. Work Phone
15. Driver’s License No. 16. Age 17. Sex
M F
18. Vehicle’s Owner’s Name and Address
19. Year Vehicle 20. Make Vehicle 21. Model Vehicle 22. Body Type 23. Vehicle Lic. No. / Equip No. / VIN
24A. Where can the Vehicle be Seen ? 24B. Describe Damage
OTHER VEHICLE INFORMATION
If more than one vehicle is involved, submit additional sheet with information on other vehicle(s).
25. Other Vehicle Driver’s Name 26. Driver’s Social Security No.
--no lon
ger required--
27. Driver’s License No. 28. Age 29. Sex
M F
30. Other Vehicle Driver’s Address (Street No.) City State Zip Code 31. Home Phone 32. Work Phone
33. Vehicle Owner’s Name and Address (Street No.) City Sta
te Zip Code
34. Year Vehicle 35. Make Vehicle 36. Model Vehicle 37. Body Type 38. Vehicle I.D. No. or Lic. No. 39. Where can the vehicle be seen ?
40. Other Vehicle Insurance Co. 41. Policy No.
42. Describe Damage 43.Estimated Amount
$
INJURED
44. Name and Address 45. Phone 46.
PED
47.
Ins. Veh.
48.
Other Veh.
49. Police Investigated ?
Yes No
44. Name and Address 45. Phone 46.
PED
47.
Ins. Ve
h.
48.
Other Veh.
49. Type Report
State Sheriff City
44. Name and Address 45. Phone 46.
PED
47.
Ins. Veh.
48.
Other Veh.
49. Report No. (Item No.)
WITNESSES OR PASSENGERS
50. Name and Address 51.
Witness
Passenger
52. Phone 53.
PED
53.
Ins. Veh.
53.
Other Veh.
53. (Specify)
50. Name and Address 51.
Witness
Passenger
52. Phone 53.
PED
53.
Ins. Veh.
53.
Other Veh.
53. (Specify)
54. State Driver’s Signature 55. Name of Driver’s immediate Supervisor and Phone No.
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Form 10.: ACCIDENT REPORT LOUISIANA STATE DRIVER SAFETY (McNeese State University)

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Completed 23 August 2020

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