DCAM/RISK MGMT - FORM 001a (01/2020)
Vehicle and Other Property Standard Liability Incident Report
OMES RISK MGMT P.O. BOX 53364 OKLAHOMA CITY, OKLAHOMA 73152 TEL: 405-521-4999 (24h), FAX: 405-522-4442
Claim number
Incident date
Time Date of agency notification
Claim form requested?
Yes No
Address/Highway City State County
Describe incident and, if vehicle is involved, draw diagram:
Photos of accident scene and location need to be taken.
Was employee aware of incident? Yes No
Non-state employee (other vehicle) information
Name Phone
Address City State Zip
Was driver or passenger injured? Yes No
Name of doct
or or hospital
Vehicle information
Year Make Model License tag #
Where damaged:
Agency information
Agency name Agency # Phone
Type of emplo
yment Full-time Temporary Volunteer Contract
Driver or employee Job Title
s Phone
Div. or Dept.
Owned By: Agency
Make Year
OMES Fleet
Vehicle Tag #
Vehicle ID #
Where damaged:
Name Address Phone
Last 4 Vehicle Vin #
DCAM/RISK MGMT - FORM 001a (01/2020)
Non-vehicle personal property damage
Describe damaged property incident:
Personal property specifics
Description Brand Type Serial Number
General questions
If state vehicle was involved in incident:
Was the vehicle involved in the accident in proper working order? Yes No
If no, explain
Was employee distracted in some way? (Cell phone, food, etc…) Yes No
If yes, explain
Was the employee issued a citation? Yes No If yes, why?
Was weather a factor in the incident? Yes No If yes, explain
If damage to property was done by equipment gate, door, etc…:
Was damage due to equipment malfunction/breakage? Yes No
Who is responsible for maintenance?
How is it maintained?
Routine maintenance performed? Yes No If so, when?
Maintenance provided by Contact information
What has been done to keep problem from reoccurring?
By signing this form you are attesting the information contained is accurate.
Employee signature Date Risk coordinator signature Date
Employee name printed Coordinator name printed