Legal Services AUTOMOBILE ACCIDENT/INCIDENT FORM

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Legal Services
AUTOMOBILE ACCIDENT/INCIDENT FORM
This form applies to automobile accidents/incidents that occur on or off the University of Windsor campus in University
owned/leased automobiles. If the accident occurs on campus, please contact Campus Police, they will then determine if the Local
Police Department should be called. If the incident happens OFF CAMPUS, please act as if you are the owner of the vehicle. Do not
admit liability. Please complete this form when you return to campus or within 48 hours of the accident/incident.
Insured’s Full Name and Address: University of Windsor
401 Sunset Ave., Windsor, ON N9B 3A8 (519) 253-3000 ext. 2080
Insurance Company:
Northbridge General Insurance #0624540
Broker’s Full Name and Address: PBL Insurance Limited
150 Ouellette Place, Windsor, ON N8X 1L9 (519) 946-0366
Policy Period:
May 1, 2012 to May 1, 2013
1. ACCIDENT /INCIDENT DETAILS
Date and Time of Accident/Incident: _______________________________________________________________
Conditions of road, weather, lightning: _____________________________________________________________
Description of Accident/Incident: __________________________________________________________________
______________________________________________________________________________________________
Location of Accident/Incident (this should include a diagram with the exact address and/or cross street):
Police Dept. to whom reported if any personal injury or damage is $1,000 or higher (attach copy of Police report
and/or report number): __________________________________________________________________________
2. DRIVER, PASSENGERS AND VEHICLE INVOLVED IN U OF W BUSINESS
Name and Address of Driver: _____________________________________________________________________
U of W contact name, department & telephone number: _______________________________________________
______________________________________________________________________________________________
Drivers' License Number: _________________________________________________________________________
VIN: __________________________________________
Year / Make of Vehicle / Colour: ___________________________________________________________________
License Plate Number: ___________________________
Remarks: current status and location of vehicle (if vehicle is towed confirm towing company): ________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Name, Address and Telephone Number of all Passengers if applicable (whether injured or not): _______________
______________________________________________________________________________________________
______________________________________________________________________________________________
Revision Date: May 2012 f
3. OTHER VEHICLE (S) OR PROPERTY DAMAGE
Year / Make of Vehicle / Colour (Note any prior damage on vehicle): ________________________________________
_________________________________________________________________________________________________
License Plate Number: ___________________________
Other Driver's Name, Address and Telephone Number: ___________________________________________________
_________________________________________________________________________________________________
Owner's Name, Address and Telephone Number (if different from above): ___________________________________
_________________________________________________________________________________________________
Other Driver's License Number: _____________________________
Owner's Driver's License Number: ___________________________
Name and Address of Other Vehicle Owner's Insurance Company: __________________________________________
_________________________________________________________________________________________________
Insurance Policy Number and Period: __________________________________________________________________
Name, Address and Telephone Number of all Passengers:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Damage to Property other than Vehicle; Name object, name, address and telephone number of owner, describe
damage (a map of location and photographs, if possible): _________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. WITNESSES
Names & addresses and telephone numbers of witnesses:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Signature of U of W Driver: ___________________________________
Date: ________________________
Signature of Department Head: _______________________________
Date: ________________________
Submit Form To: Insurance & Risk Management Officer - Julie Laforet ([email protected])
If there are any questions while filling out the form, please contact Julie at ext. 2080