HTML Preview Vehicle Damage page number 1.
THIS FORM MUST BE FILLED OUT COMPLETELY. ONLY ONE ACCIDENT,
PUBLIC INCIDENT, VANDALISM, ETC., MAY BE REPORTED ON EACH FORM.
Driver’s Report of Vehicle Damage
or Public Incident
Claimant may have the right to personal protection insurance benefits, property
insurance benefits, and/or residual liability insurance benefits if in compliance
with the Michigan no-fault insurance law. The University of Michigan will pay
claims in a timely manner as prescribed by the Michigan no-fault insurance
law. If there are any questions concerning the Michigan no-fault insurance law,
INSTRUCTIONS TO DRIVERS
In case of injury to person or damage to property:
1. Stop car and render assistance as may be needed.
2. Contact Local Police or Campus Police.
3. Fill out this form, ON THE SPOT, so far as possible;
this report is in addition to any reports filed by
UM Security or police.
4. Deliver this report promptly to the Transportation
Services Office.
5. Print all entries clearly and sign where noted.
UNIVERSITY
VEHICLE
PLEASE PRINT CLEARLY OR TYPE. DESCRIBE BELOW HOW THE ACCIDENT/INCIDENT OCCURRED GIVING DIRECTION AND
SPEED OF VEHICLE OR VEHICLES, WIDTH OF STREET OR HIGHWAY, CONDITION OF ROAD SURFACE, WEATHER, ETC., IF
APPLICABLE: (IF ADDITIONAL SPACE IS NEEDED, PLEASE ATTACH A SUPPLEMENTAL SHEET TO FORM).
Signature of Driver
NOT VALID UNLESS SIGNED
In the absence of a fully completed Driver’s Report of Vehicle Damage, all repair costs and/or deductible
may be charged to the using department. Complete both pages where applicable.
Phone
DRIVERS REPORT REVISED 10/08/12
Parts and Extent of Damages
Nature of Loss
UM #
Shortcode for Deductible
(REQUIRED)
TIME AND
PLACE OF
ACCIDENT
UNIVERSITY
DRIVER
DAMAGE TO
UNIVERSITY
CAR
1
2
3
4
STATEMENT
OF DRIVER
5
Year Make Model VIN#
License Plate # Purpose of Trip Using Department
Date Time City and State
Police Agency, Security
Police Report #
Location
ZipcodeAddress City State
ZipcodeAddress
City State
Name Employee ID# Date of Birth
Operator’s License # State Daytime Phone
Signature of Driver
Signature of Supervisor
Print Name
Print Name
Date of this Report
Date Signed
contact the Department of Insurance and Financial Services, P.O. Box 30220,
Lansing, MI 48909-7720, 877-999-6442.