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System Risk Management The Texas A&M University System MMOOTTOORR VVEEHHIICCLLEE 301 Tarrow St. 5th Floor Campus Mail 1262 ACCIDENT REPORT College Station, Texas 77840 ACCIDENT REPORT 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) Insurance 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 SYS Other Phone 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 .

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