To complete online or print from the Policy Library, use the Word link at the bottom of the page.
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Office of Finance and Business Services |
Please complete this form online and print. Complete freehand drawings, sign the form and obtain authorisation from the appropriate financial delegate (Section G) before forwarding the form and related papers to the Transport
Office, Nathan campus. Enquiries: 3735 5509.
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 |
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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 |
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| 5. Who caused the accident? | ||||||||
| 6. State your reasons for this opinion: | ||||||||
| 7. Was
this accident reported to police? |
Reported to: | Date: | ||||||
| Police Station: | ||||||||
| 8. Is police action pending? |
Give
Details: | |||||||
| 9. Show details of damage to vehicle on diagram. (Draw freehand). |
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Section C: Sketch of Accident (Draw sketch freehand) |
| 1. Draw Intersection or Street on diagram |
| 2. Show speeds of vehicles involved |
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| 5. Show Street
names |
| 6. Show Stop
& Give Way Signs (if any) as
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Example
|
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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 |
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| 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 |
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If Yes, indicate whether Postgraduate Undergraduate Uni employee Other ( ) | |||
| 5. State quantity of alcohol/drugs consumed in the 12 hours prior to accident |
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| 6. Were you requested to take a breath or blood test? (If Yes, provide details of the Type of Test.) | Yes | No | ||||
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| 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 |
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| 1. Other Vehicle Reg No: | Make/Model: | Body Type: | |||
| 2. Owner's Name and Address: |
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| 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: |
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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 |
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I authorise that costs, up to the insurance excess of $500, be charged to the following project: | _______________________________________________
Financial Delegate | |||||||||||||||||
| Project Description: | | Speedtype: | | | | | |
| | Class: | | | | |
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Section H: Transport Officer to Complete | |||
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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: | _______________________________________________________________________________ _______________________________________________________________________________ | ||
| File Name: Motor_Vehicle_Damage_Report.pdf | |
| File Size: 134203 |