Office of Finance and Business Services

Section A:  Details of University Vehicle

1.   Vehicle Registration No.:

Reg. Expiry Date:

2.   Vehicle Make & Model:

Body Type:

3.   Goods carrying vehicles only: State weight of load at time of accident 

Section B:  Details of Accident

1.   Accident Date:

Time of Accident:

   :   

 a.m./  p.m

2.   Place of Accident:

3.   Accident Details:

4.   Description of damage to university vehicle

5.   Who caused the accident?

6.   State your reasons for this opinion:

7.   Was this accident reported to police?

 No

 Yes

Reported to:

Date:

Police Station:

8.   Is police action pending?

 No

 Yes

Give Details:

9.   Show details of damage to vehicle on diagram. (Draw freehand).

Section C:  Sketch of Accident

(Draw sketch freehand)

1.   Draw Intersection or Street on diagram

2.   Show speeds of vehicles involved

3.   Show your vehicle and direction of travel as    A

4.   Show other vehicle and direction of travel as   B

5.   Show Street names

6.   Show Stop & Give Way Signs (if any) as

                         Stop                     Give Way

7.   Show directional lane arrows i.e. Arrows painted on road (if any) e.g.

Condition of road e.g. wet, dry etc

Was your vehicle on the correct side of the road?

 Yes      No

If after sundown, were lamps alight in accordance with the relevant laws?

 Yes      No

Section D:  Witnesses and Persons Injured
If Staff or Students are injured they must also complete the Incident/Injury Report form.

1.   Names / Addresses of Persons who witnessed accident:

2.   Names / Addresses of persons injured in accident:

3.   Name of Doctor and/or Hospital:

Section E:  Details of Driver of University Vehicle

1.   Name of Driver:

Element/School:

Ext No:

2.   Licence No.:

Class:

Expiry Date:

(Please attach a copy of your driver's licence (Front/ Back))

3.    Driver's Birth Date

Licensed since:

4.   Is the driver authorised to drive University vehicles?

 Yes

 No

If Yes, indicate whether

    Postgraduate

    Undergraduate

    Uni employee

    Other (      )

5.   State quantity of alcohol/drugs consumed in the 12 hours prior to accident

6.   Were you requested to take a breath or blood test?  (If Yes, provide details of the Type of Test.)

 Yes

 No

7.   Has the driver or person in charge: ever had licence endorsed, suspended, cancelled, or been convicted of a traffic offence in the past 5 years? (If Yes, attach full details)

 Yes

 No

Section F:  Particulars of Damage to Other Vehicle and Property

1.   Other Vehicle Reg No:

Make/Model:

Body Type:

2.   Owner's Name and Address:

3.   Driver's Name and Address:

4.   Details of Damage to Other Vehicle:

5.   Name of Insurer of Other Vehicle:

6.   Brief Details of Property Damage (other than Motor Vehicles):

7.   Property Owner's Name and Address:

8.   Name of Insurer:

Section G:  Certification by the Person in Charge of the Vehicle and Financial Delegate

The information in this form is true and correct and no information relevant to this incident has been withheld.

Signature(s):

_______________________________________________________

Date

     /     /

Please print name(s) of person(s) signing this form 

I authorise that costs, up to the insurance excess of $500, be charged to the following project:

_______________________________________________ Financial Delegate

Project Description:

Speedtype:

Class:

Section H:  Transport Officer to Complete

1.   Full Damage Description

Signed (Transport Officer):

Date

     /     /

Section I: Insurance Officer

1.   Date Repairs Authorised:

      /       /

7.    Actual Repair Cost:

$ ____________________

2.   Name of Repairer:

_________________________________

8.    Dept Excess:

$ ____________________

3.   Estimated Cost of Repairs:

$ ______________________

9.    T.P. Repair Costs:

$ ____________________

4.   VDR No.:

__________/ ________

10.  T.P. Excess:

$ ____________________

5.   Fault code:

_________________________________

11.  T.P. Recovery:

$ ____________________

6.   Estimate No.:

_________________________________

Date:

         /      /

12. General:

_______________________________________________________________________________

_______________________________________________________________________________