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)
Witnesses? Yes No
Witness name
Witness phone
Witness 1
Witness 2
Continued on next page
Vehicle Crash/Damage Notice form-ver. 2-2017 page 1 of 2
Vehicle Crash/Damage Notice
Section 6: Other Vehicle(s) (if more than one vehicle, please use Additional Information section below)
License plate: State Vehicle VIN:
Make: Model: Year:
Description of damage to other vehicle (take photos and include with report if possible):
Were photos taken? Yes No Was the vehicle towed from the scene? Yes No
Section 7: Other Vehicle Owner
Owner first name: Last name:
Address: City: State: Zip:
Email: Phone number:
Insurance company: Policy number:
Section 8: Other Vehicle Driver
Driver first name: Last name:
Address: City: State: Zip:
Email: Phone number:
License number: Driver injuries reported or evident? Yes No If yes, describe injuries:
Section 9: Passengers (if more than space provides, please use Additional Information section below)
Passenger name
Phone
Which vehicle?
Insured Other
Insured Other
Insured Other
Insured
Other
Section 10: Property Damage (non-vehicle)
Was there other property damaged (non-vehicle)? Yes No
Last name:
City: State: Zip:
Phone number:
Property owner first name:
Address:
Email:
Description of (non-vehicle) property damage:
Section 11: Additional Information
Phone:
Section 12: Person Completing Form
Name:
Email:
Date completed:
page 2 of 2
Date management notified of incident:
Vehicle Crash/Damage Notice form-ver. 2-2017
CLICK TO SUBMIT FORM BY EMAIL
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