The university of north carolina at chapel hill



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AUTOMOBILE LOSS NOTICE

DATE

     


INSURED

NAME & ADDRESS

THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

C/O THE STATE OF NORTH CAROLINA

RISK MANAGEMENT SERVICES

104 AIRPORT DRIVE, CAMPUS BOX 1100

CHAPEL HILL, NC 27599-1100

UNC CONTACT

Janet Hoernke janet_hoernke@unc.edu

PHONE

(919) 962-6681

(919) 962-0636 (fax)

UNC CLAIM NO.
For Internal Use

COMPANY

The Travelers

POLICY NO.

TRJCAP-104T6800 or

660-826F2846

LOSS RUN CODE
For Internal Use

LOSS DETAILS

LOCATION OF ACCIDENT

     


DATE & TIME OF LOSS

     


AUTHORITY CONTACTED & REPORT NO.

     


VIOLATIONS / CITATIONS

     


DESCRIPTION OF ACCIDENT

     

     

     


STATE OPERATED VEHICLE & DRIVER INFORMATION

VEH. NO.

     


YEAR, MAKE, MODEL

     


V.I.N. (Vehicle Identification)

     

PLATE NO.

     

UNC-OWNED RENTAL MOTOR FLEET OTHER

DRIVER'S NAME & HOME ADDRESS

     

PHONE

     

DATE OF BIRTH

     

DRIVER'S LICENSE NO.

     

PURPOSE OF USE

     

USED WITH PERMISSION?

     

DRIVER'S UNC DEPT.

     

UNC DEPT. NO.

     

PHONE

     

SUPERVISOR

     

DESCRIBE DAMAGE

     

ESTIMATE AMOUNT

     

WHERE VEHICLE CAN BE SEEN

     

WHEN?

     

PROPERTY DAMAGED

DESCRIBE PROPERTY (If auto, year, make, model, plate no. and color)

     


INSURANCE OR AGENCY NAME & POLICY NO.

     

OWNER'S NAME & ADDRESS

     

BUSINESS PHONE

     

RESIDENCE PHONE

     

OTHER DRIVER'S NAME & ADDRESS (Check if same as owner)

     

BUSINESS PHONE

     

RESIDENCE PHONE

     

DESCRIBE DAMAGE

     

ESTIMATE AMOUNT

     

WHERE VEHICLE CAN BE SEEN?

     

WHEN?

     

INJURED

NAME & ADDRESS

     


PHONE

     


UNC VEHICLE, OTHER VEHICLE OR PEDESTRIAN?

     


EXTENT OF INJURY

     

     

     


     

     

     

     


     

     


WITNESSES OR PASSENGERS

NAME & ADDRESS

     


PHONE

     


UNC VEHICLE, OTHER VEHICLE OR PEDESTRIAN?

     


EXTENT OF INJURY

     

     

     

     

     

















ADDITIONAL COMMENTS

     

     

     





REPORTED BY

     


SIGNATURE OF STATE OPERATED VEHICLE DRIVER

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