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Driver's Telephone*18. Driver's or Chauffeur's License Number>19. If driver was not the owner, give owner's name and address&Insured By (name of insurance company)4Insurance Agent (name, address and telephone number)INJUREDAREA CODE & PHONENAME AND ADDRESSWITNESSES OR PASSENGERSACCIDENT INFORMATIONUM VEH.OTHERPED.20.21.22.23.24.LOSS INFORMATION28. Year, Make and Model of Car29. License Number and State36. Year, Make and Model of Car37. License Number and State!30. Vehicle Identification Number31.38. Describe Damage to Vehicle32. Used with Permission33. Describe Damage to VehiclePlease note - for items 34, 35, 39 & 40, if information is not readily available, do not delay report, simply forward repair estimates as soon as possible734. Name and address where vehicle was taken for repair739. Name and address where vehicle was taken for repair35. Estimated Cost to Repair40. Estimated Cost to Repair$LIGHT (Check one) Specify OtherWEATHERROAD CHARACTER ROAD SURFACE*Driving under the influence of intoxicantsUntrained or unskilled"Abstracted-thinking of job detailsHurry or Impatience!Irritated-by another driver, etc. Distracted#Fatigue-long driving, lack of sleep111-physical weakness Other causes:CAUSE OFUNSAFE DRIVING ACTOtherDriving too fast-or too slowDid not grant right of wayFollowed too closelyOn wrong side of road or laneFailed to give proper signalDisregarded stop signImproper passing Improper turnDisregarded stop and go light!Disregarded other traffic control&Improper starting from parked positionImproper backing maneuverOther improper actionsSeat Belts Worn? Yes - No - No improper driving or parkingjWhat action has or will be taken to prevent recurrence: (Attach a separate sheet if more space is needed):MoCodeSupervisor's SignatureTitleDate%Campus Claims Coordinator's Signature Deductibles: <$500 for liability for owned or rented and collision claims:No unsafe driving act-SUPERVISOR'S REPORT OF ACCIDENT INVESTIGATION (Check One)1.Date Report Prepared4.Department Telephone7.SPlace of Accident (city, state; if on a highway, give number and nearest community)8. Driver's Name10.Driver's University Address11.University Telephone13.(Purpose for which vehicle was being used25.26.27.<Was a law enforcement agency notified? If so, name of agencyWWas citation issued as a result of accident? If so, to whom issued and for what reason?ZBrief description of accident (speed, traffic, road conditions, seat belts, signals, etc.)This report is to be completed in the event any of the following vehicles are involved in an accident. (1) any University-owned vehicle; (2) any employee-owned vehicle used on official University business; and (3) any vehicle rented or leased by or for the University. This form is to be typed (original only). The Department Chairperson or Supervisor should complete the Supervisor's Report of Accident Investigation section, and forward to the Campus Claims Coordinator within 48 hours after the accident.INDICATE Use one of these outlines to sketch the scene of your accident; OUTLINE ROADWAY WITH SOLID LINES AND IDENTIFY BY ARROW ALL STREETSd$250 for comprehensive; $0 for physical damage to a commercially rented automobile (i.e. Enterprise) UM 5 (OCT 11) 14a. OwnerUM 5 (MAY 16) 5/23/16uNOTE: You must print both Page 1 and Page 2 of the form. 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