STATE OF CALIFORNIA - DGS ORIM
VEHICLE ACCIDENT REPORT
STD. 270 (REV. 2/2002c)
ACCIDENT PREVIOUSLY REPORTED TO ORIM? (If Yes, give date)
YES NO
THIS REPORT MUST BE MAILED WITHIN 48 HOURS AFTER ACCIDENT
(ACCIDENTS INVOLVING INJURY SHOULD FIRST BE CALLED OR FAXED
TO ORIM AT (916) 376-5302 - CALNET 480-5302 - FAX (916) 376-5277.)
* CONFIDENTIAL INFORMATION *
DO NOT RELEASE TO OTHER PARTIES WITHOUT CONSENT OF THE
OFFICE OF RISK AND INSURANCE MANAGEMENT
DISTRIBUTION: OFFICE OF RISK AND
ORIGINAL - INSURANCE MANAGEMENT
707 THIRD STREET, FIRST FLOOR
WEST SACRAMENTO, CA 95605
COPY - STATE GARAGE (DGS pool vehicle only)
COPY - DEPT. FILES (Dept. owned vehicles only)
COPY - STATE DRIVER
(Dept. owned vehicles only)
Page
of
DRIVER
NAME
STATE
AGE EMPLOYING DEPARTMENT AGENCY BILLING CODE
DRIVER’S LICENSE NO. ACCIDENT DATE TIME
OFFICE ADDRESS
AGENCY DOCUMENT NO.
(Optional)
WAS VEHICLE BEING USED ON OFFICIAL
STATE BUSINESS?
(If NO, attach explanation)
YES NO
DATE DRIVER LAST COMPLETED
Month/Year
JOB TITLE BUSINESS TELEPHONE
STATE DEFENSIVE
NOT TAKEN
DRIVER TRAINING
STATE
VEHICLE
VEHICLE LICENSE NUMBER
VEHICLE YEAR, MAKE, MODEL VEHICLE OWNER DEPT. VEHICLE NO.
(Optional)
DEPARTMENT OWNED DGS POOL
DESCRIBE DAMAGES TO STATE VEHICLE
ESTIMATED
REPAIR COST
RENTAL EMPLOYEE OWNED
IF DEPARTMENT OWNED OR RENTAL, ENTER OWNER’S NAME
ACCIDENT DETAILS
(See Reverse for Diagram and Description)
ACCIDENT LOCATION (Address/Area)
ROAD CONDITIONS
WEATHER CONDITIONS
(City/State) TRAFFIC CONDITIONS
(County) HOW FAST WERE YOU DRIVING? EST. SPEED OF OTHER CAR
POLICE REPORT MADE
NAME AND ADDRESS OF INVESTIGATING AGENCY
YES NO
AGENCY
CHP OTHER
OTHER VEHICLE
DRIVER’S NAME AGE / DOB VEHICLE LICENSE NUMBER VEHICLE YEAR, MAKE, MODEL NO. OF PASSENGERS
DRIVER’S LICENSE NO. HOME TELEPHONE WORK TELEPHONE REGISTERED OWNER
DRIVER’S ADDRESS (Street, City, State, Zip Code)
OWNER’S ADDRESS
HOME TELEPHONE
WORK TELEPHONE
BRIEFLY DESCRIBE DAMAGES TO OTHER VEHICLE OR PROPERTY
NAME AND ADDRESS OF OTHER PARTY’S INSURANCE
INJURED
NAME AGE
ADDRESS HOSPITAL
NAME AGE ADDRESS HOSPITAL
WITNESS
NAME TELEPHONE ADDRESS
NAME TELEPHONE ADDRESS
VEHICLE PASSENGERS
OTHER STATE
NAME ADDRESS
NAME ADDRESS
NAME ADDRESS
NAME ADDRESS
(CONTINUE ON REVERSE)
