Instructions for Completing Auto Loss Notice

Time and Place of Accident:

Enter the Date, time, and specific address of accident.

About Your Auto:

Enter the Make, Year, Model, VIN of vehicle, License Plate #, Name of driver, driver’s home address, Driver’s phone number and hire date. Dept, Supervisor’s name, Sup. Phone number, Driver’s license in effect? Driver's title, Where were you going when accident happened? Where were you coming from? Business or Pleasure? Who gave permission - Supervisor’s name, & title, purpose of use, description of all damages to vehicle, detailed. Where is the vehicle now (repair shop, parking lot?) Estimated cost of repairs (rough idea)

Other Auto Involved:

Enter other vehicle involved information in this section, as well as contact information for other driver/owner and insurance information.


List passengers in state vehicle and other involved vehicle


List any injuries of state employee, other involved driver, and passengers.


List any witnesses to the accident.

Property Damage Other Than Auto:

To be completed when state vehicle causes damage to non-auto property (i.e., truck hitting overhang of building).

Description of Accident:

Complete section to the best of your ability. Did Police Investigate Accident: Were police called? Police Address: Which agency responded (i.e., State, U.Va., County)?

Glass Breakage:

Complete this section for any glass breakage to the state vehicle.

Date of Report:

Date report filed.


Driver must print name and sign form.

If you should have any questions regarding the completion of this form, contact Property & Liability Risk Management at (434) 924-3055.

UVA Affiliation or Organization