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
|
