AUTOMOBILE LOSS NOTICE
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DATE
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INSURED
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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
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UNC CONTACT
Janet Hoernke janet_hoernke@unc.edu
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PHONE
(919) 962-6681
(919) 962-0636 (fax)
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UNC CLAIM NO.
For Internal Use
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COMPANY
The Travelers
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POLICY NO.
TRJCAP-104T6800 or
660-826F2846
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LOSS RUN CODE
For Internal Use
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LOSS DETAILS
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LOCATION OF ACCIDENT
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DATE & TIME OF LOSS
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AUTHORITY CONTACTED & REPORT NO.
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VIOLATIONS / CITATIONS
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DESCRIPTION OF ACCIDENT
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STATE OPERATED VEHICLE & DRIVER INFORMATION
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VEH. NO.
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YEAR, MAKE, MODEL
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V.I.N. (Vehicle Identification)
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PLATE NO.
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UNC-OWNED RENTAL MOTOR FLEET OTHER
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DRIVER'S NAME & HOME ADDRESS
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PHONE
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DATE OF BIRTH
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DRIVER'S LICENSE NO.
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PURPOSE OF USE
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USED WITH PERMISSION?
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DRIVER'S UNC DEPT.
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UNC DEPT. NO.
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PHONE
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SUPERVISOR
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DESCRIBE DAMAGE
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ESTIMATE AMOUNT
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WHERE VEHICLE CAN BE SEEN
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WHEN?
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PROPERTY DAMAGED
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DESCRIBE PROPERTY (If auto, year, make, model, plate no. and color)
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INSURANCE OR AGENCY NAME & POLICY NO.
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OWNER'S NAME & ADDRESS
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BUSINESS PHONE
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RESIDENCE PHONE
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OTHER DRIVER'S NAME & ADDRESS (Check if same as owner)
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BUSINESS PHONE
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RESIDENCE PHONE
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DESCRIBE DAMAGE
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ESTIMATE AMOUNT
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WHERE VEHICLE CAN BE SEEN?
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WHEN?
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INJURED
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NAME & ADDRESS
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PHONE
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UNC VEHICLE, OTHER VEHICLE OR PEDESTRIAN?
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EXTENT OF INJURY
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WITNESSES OR PASSENGERS
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NAME & ADDRESS
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PHONE
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UNC VEHICLE, OTHER VEHICLE OR PEDESTRIAN?
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EXTENT OF INJURY
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ADDITIONAL COMMENTS
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REPORTED BY
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SIGNATURE OF STATE OPERATED VEHICLE DRIVER
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