Fillable Wilkes University - Vehicle Incident Report

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Wilkes University - Vehicle Incident Report

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Country of origin: US
File type: PDF

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RISK MANAGEMENT
Wilkes University
84 West South St.
Wilkes-Barre, PA 18766
Justin Kraynack
Chief Risk & Compliance Officer
570-408-4554
justin.kraynack@wilkes.edu
INCIDENT REPORT
MOTOR VEHICLE ACCIDENT
Email or fax completed form within 48 hours of incident. Email: Justin.kraynack@wilkes.edu Fax: 570-408-4985
The University driver should complete this form to report an accident that involved a University owned, leased or rented vehicle.
ACCIDENT DETAILS
Date of Incident:
Campus Responsible for Vehicle: ________
Weather Conditions:
Road Conditions:
Location of Accident:
City:
State:
Zip:
Police Investigation Yes No
Town:
Report #:
Officer Name:
Local Police
Sheriff
State Police
Description of Accident (Attach additional sheets if needed):
UNIVERSITY DRIVER AND VEHICLE INFORMATION
Name:
Campus: ________
Dept:
Birth Date:
Phone:
Email:
Employee Student Other:
Driver’s License #:
State:
Plate#:
Make:
Model:
Year:
Passenger Yes No
Name:
Phone:
Email:
Passenger Yes No
Name:
Phone:
Email:
Describe Vehicle Damage:
OTHER DRIVER AND VEHICLE INFORMATION
Name:
Phone:
Email:
Address:
City:
State:
Zip:
Driver’s License #:
Birth Date:
Plate #:
Plate State:
Make:
Model:
Year:
Color:
Passenger Yes No
Name:
Phone:
Email:
Passenger Yes No
Name:
Phone:
Email:
Insurance Policy #:
Ins. Company:
Ins. Agency:
Vehicle Owner:
Phone:
Email:
Owner Address:
City:
State:
Zip:
Describe Vehicle Damage:
INJURIES(If more than one person injured, attach additional sheets)
Name:
Phone:
Email:
Address:
City:
State:
Zip:
Visitor
Student
Other:
Age, if minor:
Describe Injury:
Witnesses (Other than passengers. If more witnesses, attach additional sheets)
Name:
Phone:
Email:
Address:
City:
State:
Zip:
Name:
Phone:
Email:
Address:
City:
State:
Zip:
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Wilkes University - Vehicle Incident Report

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Completed 19 November 2019

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