Accident Form

UCSD VEHICLE ACCIDENT/INCIDENT REPORT

Get What You Wanted?

Please complete with as much information as possible
Vehicle UCSD ID #:		Vehicle License:
Accident Date (mm/dd/yyyy):		Accident Time:
Location (Street, City):		Weather Condition:
Other (please specify):

Check if the Police were at the scene.	Which enforcement agency responded ?
Check if a Police Report was taken.	Police Report #:

1. Driver's Information
Last Name:		First Name:
Driver License #:		Expiration Date (mm/dd/yyyy):
DOB (mm/dd/yyyy):		Phone Ext:
Department:		Supervisor Name:
		Supervisor Phone Ext:

2. Passengers / Witnesses

Name	Address	Phone	Was this person injured ?
			Yes
			Yes
			Yes
			Yes
			Yes
			Yes

Complete this section if another vehicle was involved, otherwise skip to section 4. Describe the Accident/Incident.

3. Other Driver's Information

Last Name:		First Name:
Street Address:		City:
State:		Zip Code:
Driver License #:		Expiration Date (mm/dd/yyyy):
Vehicle License:		Vehicle Year (yyyy):
Vehicle Make:		Vehicle Model:
Insurer Name:		Policy Number:
Insurer Phone:

If the registered owner of the vehicle is different than that information contained in section 3 above, then please complete the following:

Last Name:		First Name:
Phone:		Address:
City:		State:
Zip Code:

4. Describe the Accident/Incident

Give the street names, showing the directions and the locations of the objects involved. Make sure to describe clearly the area on the vehicle where the contact was made.
There is an Accident Report Form in the vehicle. If possible, use the form to make a drawing of the scene referring to the vehicle UCSD ID number and FAX it to (858) 534-2051.