Vehicle Accident Report Form

Use this form to report a vehicle incident involving an NSHE, University, or College Vehicle.

This form is a replacement for Form URM-002.

Driver's Name:

Institution:

Phone Number:

Work Email:

State where your driver's license was issued:

Driver's License Number:

Driver's License Expiration:

Supervisor's Name:

Vehicle Identification Number (VIN, 17 digits): 17 digit number found on the vehicle registration paper, or on the insurance card, or on the vehicle (drivers side lower dashboard facing the front windshield or on a sticker on the drivers side door jamb.

Vehicle License Plate State:

Vehicle License Plate Number:

Vehicle Year:

Vehicle Make/Manufacturer:

Vehicle Model:

Where is the Vehicle Currently Located?

Date of Accident:

Time of Accident:

Location of Accident:

Were the Police Involved or at the Scene?

Choose a Police Department:

If Other, Please Specify:

Police Report Number:

Upload Relevant Files (Max 10 files): Upload any relevant files such as photos, police reports, drawings of the accident scene, etc. A maximum of 10 files can be uploaded.

Incident Description: Describe the incident in as much detail as possible, including location.
Describe the damage to the NSHE vehicle. Use locational words such as driver's side, front bumper, passenger side rear window, etc.
Use directional descriptions such as traveling west, northbound, etc.
Describe weather conditions.
Approximate time - was it during the daylight, nighttime?

Do You Have the Other Party's Vehicle Information?

Their Insurance Company:

Their Vehicle Insurance Policy Number (On insurance card):

Insurance Claims Phone Number:

Vehicle License Plate State (Nevada, etc.):

Vehicle License Plate Number:

Do you have the other vehicle owners information?

Vehicle Owner's Name: This information is usually found on the vehicle registration or vehicle insurance card.

Vehicle Owner's Address:

Vehicle Owner's Phone Number:

Is the vehicle owner different from the Driver? If so, do you have the other driver's information?

Driver's Name:

Driver's Address:

Driver's Phone Number:

State where the driver's license was issued:

Driver's License Number:

Driver's License Expiration Date:

Are there any witnesses?

Witness Name: Witness Telephone Number: Witness Email:

Name	Telephone	Email	Remove

Are there any third-party reported injuries? This section is for any third-party (non-NSHE employee) who was injured. If you are an NSHE employee and were injured, fill out a workers comp form C-1 and notify your supervisor.

Injured Party Name: Injured Party Address: Injured Party Telephone Number: Injured Party Email: Primary Complaint:

Name	Address	Telephone	Email	Injury	Remove

I verify that the information submitted on this form is true and correct to the best of my knowledge. By typing my name below, an electronic signature will be created. My electronic signature will be treated in all respects as having the same force and effect as an original (wet) signature. By selecting the submit button, I agree with the aforementioned statement.

Full Name: