Rowan university auto accident report form for non-university vehicles



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ROWAN UNIVERSITY AUTO ACCIDENT REPORT FORM FOR NON-UNIVERSITY VEHICLES

THIS FORM IS FOR UNIVERSITY USE ONLY AND DOES NOT SUPERSEDE THE STATE OF NJ RM-1A FORM FOR ACCIDENTS INVOLVING ROWAN UNIVERSITY VEHICLES



All auto accidents regardless of severity must be reported to the

Office of Risk Management & Insurance within 24 hours


ROWAN EMPLOYEE/DRIVER INFORMATION

Name:      

Driver’s License#:      

Street Address:      

City:      

State:      

Zip Code:      

Tel:      

Vehicle Year:      

Make:      

Model:      

License Plate:      

Department:      

Supervisor:      

ACCIDENT INFORMATION

Did Rowan University Public Safety report to the scene of the accident?* Yes No

Did state or local police report to the scene of the accident?* Yes No

* If Yes to either of the above provide copies of the police report to Risk Management

Date of Accident:      

Time of Accident:      

AM PM

Street Name:      

Weather Conditions:      

City:      

State:      

Road Conditions:      

Leaving From:      

Going To:      

Purpose of Trip:      


INFORMATION REGARDING INJURED PARTIES

Name:      

Age:      

Address:      

Tel:      

Nature of Injury:      

Was injured person transported to hospital? Yes No

Hospital:      

Injured was: In your Vehicle (1) In other vehicle (2) Pedestrian

Name:      

Age:      

Address:      

Tel:      

Nature of Injury:      

Was injured person transported to hospital? Yes No

Hospital:      

Injured was: In your Vehicle (1) In other vehicle (2) Pedestrian

Name:      

Age:      

Address:      

Tel:      

Nature of Injury:      

Was injured person transported to hospital? Yes No

Hospital:      

Injured was: In your Vehicle (1) In other vehicle (2) Pedestrian

Name:      

Age:      

Address:      

Tel:      

Nature of Injury:      

Was injured person transported to hospital? Yes No

Hospital:      

Injured was: In your Vehicle (1) In other vehicle (2) Pedestrian



FACTS REGARDING OTHER VEHICLE

Driver’s Name:      

Age:      

Address:      

Tel:      

Make & Year of Vehicle:      

Insurance Company:      

License Plate Number:      

Nature of Damages:      


WITNESS INFORMATION

Name:      

Name:      

Address:      

Address:      

Tel:      

Tel:      

Name:      

Name:      

Address:      

Address:      

Tel:      

Tel:      


DESCRIBE THE ACCIDENT


Show North with Arrow





1



2



Your Vehicle: 1 Other Vehicle: 2 Pedestrian: +




Describe the Accident:

     


Nature of Vehicle Damages (Take pictures if possible):

     


Property Damage other than Vehicle (Fence, Utility Pole, etc.):      

Damaged Property Owner’s Name:      

Tel:      

Street Address:      

City:      

State:      

Zip Code:      

SIGNATURES

Employee/Driver’s Signature:

Date:      

Supervisor’s Signature

Date:      



Rowan University

Office of Risk Management & Insurance



(856) 256-4370

Directory: rmi

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