NSHE Vehicle Accident Report Form

Vehicle Accident Report Form

Contact Person

Campus (required)

Contact Person's Name (required)

Email (required)

Phone

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NSHE Driver's Information

Driver's Name (required)

Agency/Department

Office Address (required)

City (required)

State (required)

Zip Code (required)

Driver's License Number (required)

Issuing State (required)

Expiration Date (required)

NSHE Vehicle Information

Vehicle ID Number (VIN) for NSHE vehicle (required)

EX Plate Number for NSHE vehicle (required)

Year for NSHE vehicle (required)

Make for NSHE vehicle (required)

Model for NSHE vehicle (required)

Describe damage to State Vehicle

Windshield damage only; no other party involved

Was another driver involved in this accident? (required)
YesNo

Other Driver's Information

Self-insurance card provided to driver/owner? (required)
YesNo

Owner's Name (required)

Phone of other vehicle owner (required)

Owner's Street Address of other vehicle owner

City of other vehicle owner

State of other vehicle owner

Zip Code of other vehicle owner

Owner's Insurance Company

Owner's Insurance Policy Number

Owner's Insurance Policy City

Owner's Insurance Policy State

Owner's Insurance Agent

Insurance Agent's Phone

Is the driver in the other vehicle different from the owner of the vehicle? (required)

YesNo

Driver's Name

Phone of other vehicle's driver

Driver's Street Address of other vehicle owner

City of other driver

State of other driver

Zip Code of other vehicle driver

Other Driver's License Number

Issuing State for other driver's license

Expiration Date for other driver's license

Other Vehicle Information

Describe damage to other vehicle and any injuries reported

Details of Accident

Date of Accident (required)

Time of Accident (required)

Street Address where accident occurred of other vehicle owner

City where accident occurred

State where accident occurred

Zip Code where accident occurred

Explain What Happened

Accident Reported to (NHP, Campus Police, or local law enforcement)

Report #

Citations Issued?
YesNo

If "Yes," explain

Witnesses (Please include Name, Address, and Phone Number)

Witness card given/statement taken

Persons Injured (If injured person is a NSHE Employee, complete a Worker’s Compensation Claim Form.)

Please attach any supporting documents, including damage estimates and diagrams of the accident

(Please note: Documents must not exceed 5MB in size)

NSHE Organizations

NSHE Institutions

Vehicle Accident Report Form

Contact Person

NSHE Driver's Information

NSHE Vehicle Information

Other Driver's Information

Other Vehicle Information

Details of Accident

Office Resources

Departments

North

South

NSHE Organizational Units

Our Institutions