Vehicle Crash/Damage Notice
NOTE: If incident involves serious injury or fatality,
please call 651-201-2594 as soon as possible.
Instructions:
1. Use this form for all owned, leased, or rented vehicle (on-road/off-road) crashes or vehicle damage
incidents. You may use your own form if it includes all the requested data.
2. Complete as much information as possible and submit within 24 hours.
3. Submit by email to claims.rmd@state.mn.us
(preferred) or by fax: 651-297-7715
4. To report general liability or property incidents/claims please see instructions at mn.gov/admin/risk
Section 1: Insured Entity
Agency/Campus: Address:
Contact person: Email: Phone:
Section 2: Insured Vehicle Information
License Plate: Vehicle VIN:
Make: Model: Year: Asset/unit number:
Driver first name: Last name:
Email: Phone number:
Section 3: Incident Information
Type of incident: Windshield/glass only Crash Other Incident date: Time: am pm
Location: (street/highway or location details):
City: State:
Section 4: Incident Details
Involves injuries to others?
Yes No Involves property damage of others? Yes No
Law enforcement at scene?
Yes No If yes, which police department?
Were citations issued?
Yes No If yes, which driver? Insured driver Other driver
Number of vehicles involved:
Number of passengers in vehicles: (c
omplete Section 9)
Describe incident in detail sufficient to
Diagram what happened (you can use Adobe comment feature to draw):
determine causes:
Label insured vehicle and indicate north
Description of damage to insured vehicle (take photos and include with report if possible):
Were photos taken? Yes No Was the vehicle towed from the scene? Yes No
Section 5: Witnesses (if more than space provides, please use Additional Information section below)
Continued on next page
Vehicle Crash/Damage Notice form-ver. 2-2017 page 1 of 2
