System Risk Management The A&M University System MMOOTTOORR VVEEHHIICCLLEE 301 Tarrow St. 5th Floor Campus Mail 1262 AACCCCIIDDEENNTT RREEPPOORRTT College Station, Texas 77840 Phone Number: (979) 458-6330 Fax Number: (979) 458-6247

Date Of Day of AM DATE Accident Week Hour PM

Highway/Street/Road on which Under Construction Accident Occurred Yes No

LOCATION County City or Town State OF ACCIDENT AT ITS INTERSECTION WITH

IF NOT INTERSECTION FEET OF Show intersecting street or highway, house no., bridge, RR crossing, alley, N S E W driveway, culvert, milepost, underpass, or other landmark.

SYSTEM Year Make/ Model Plate No.

VEHICLE Seat Belts V.I.N.: Unit Number In Use Yes No (Owned or Non-Owned) Member Name Department

Driver System Employee? (Yes or No) DRIVER INFORMATION Towing Trailer Yes No Cell Phone Work Phone

Trailer Yr., Make, Model Owner

(Property struck by Driver’s Driver’s Driving Approximate vehicle, see “Property Damage” below) Occupation License No. Experience (yrs) Damage

Date of Speed You Type of License Birth Were traveling mph Class A Class B Class C Com. Op

OTHER Year Type & Make Vehicle VEHICLE Model Vehicle License No.

Driver Address Phone DRIVER (Include City and State) INFORMATION Owner Address Phone (Include City and State) (Other Vehicle Driver’s Date of Birth Driver’s License Number involved in accident) Company Policy Number

Agent Address Phone

OTHER Describe Property

PROPERTY Owner Address Phone DAMAGE (Not Vehicle) Describe Damage Estimate Damage

PED SYS Other Age EXTENT OF INJURY Phone Veh Veh Name & Address

Name & Address INJURED Name & Address

Name & Address

System Form 9 Complete Information on Back Side

Phone SYS Other OTHER (SPECIFY) Veh Veh Name & Address

WITNESSES Name & Address OR Name & Address PASSENGERS

Name & Address

POLICE Police Report REPORT Yes No If yes, please state which agency

Case No. Phone Number CITATION ISSUED Officer Name Charge(s)

Was System Vehicle in Emergency Response? Yes No PURPOSE OF Brief Explanation of Trip Purpose: TRIP

Briefly describe how accident occurred (Driver’s Statement)

NARRATIVE

OF ACCIDENT

DIAGRAM ACCIDENT TYPE Indicate North Check Applicable Box C Head-on Collision Collision with Fixed Object O Rear-End Collision Ran Red Light/Stop Sign M Hit and Run Collision Collision with Pedestrian Collision with Bicyclist or Motorcycle P Backed without Safety Vehicle Roll Over/Jackknife L Changing Lanes Collision Passing and/or Turning Collision E Collision between two State Vehicles/Equipment Collision with Parked Vehicle T Object Thrown from/by State Vehicle Hit in Side by Other Vehicle E Struck by Falling or Flying Objects Collision with Animal (wild or domestic) Fire Theft Vandalism Windshield Failed to Yield Right of Way

Other

Supervisor’s Name Title Phone #

Date Driver’s Signature

PLEASE NOTE: You must notify Risk Management by creating a new incident in Origami, along with a scan of the MVAR, within 48 hours.

For further information or support, please contact your Vehicle Coordinator or System Risk Management. You can also visit System Risk Management’s web site http://www.tamus.edu/business/risk-management/

As of 10.01.2020