{"id":5224,"date":"2024-03-08T11:34:18","date_gmt":"2024-03-08T19:34:18","guid":{"rendered":"https:\/\/nshe.nevada.edu\/system-administration\/?page_id=5224"},"modified":"2024-09-11T10:05:32","modified_gmt":"2024-09-11T17:05:32","slug":"nshe-vehicle-accident-report","status":"publish","type":"page","link":"https:\/\/nshe.nevada.edu\/system-administration\/departments\/risk-management\/nshe-vehicle-accident-report\/","title":{"rendered":"NSHE Vehicle Accident Report Form"},"content":{"rendered":"\n    <div id=\"\" class=\"card-standard content-box default-shadow   \">\n        <div class=\"content-box-header\">\n            <div class=\"columns\">\n                <div class=\"column\">\n                    <h2>Vehicle Accident Report Form<\/h2>\n                <\/div>\n            <\/div>\n        <\/div>\n        <div class=\"institution-border\">\n            <svg class=\"border-block csn\"><rect  \/><\/svg>\n            <svg class=\"border-block dri\"><rect  \/><\/svg>\n            <svg class=\"border-block gbc\"><rect  \/><\/svg>\n            <svg class=\"border-block nsc\"><rect  \/><\/svg>\n            <svg class=\"border-block tmcc\"><rect  \/><\/svg>\n            <svg class=\"border-block unlv\"><rect  \/><\/svg>\n            <svg class=\"border-block unr\"><rect  \/><\/svg>\n            <svg class=\"border-block wnc\"><rect  \/><\/svg>\n        <\/div>\n        <div class=\"content-box-body\">\n            \n<div>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f5225-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"5225\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/system-administration\/wp-json\/wp\/v2\/pages\/5224#wpcf7-f5225-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"5225\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.2\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f5225-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<h3>Contact Person\n<\/h3>\n<div class=\"columns\">\n\t<div class=\"column is-half\">\n\t\t<p><label><strong>Campus<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"campus\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"campus\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"College of Southern Nevada\">College of Southern Nevada<\/option><option value=\"Desert Research Institute\">Desert Research Institute<\/option><option value=\"Great Basin College\">Great Basin College<\/option><option value=\"Nevada State University\">Nevada State University<\/option><option value=\"System Administration\/System Computing Services\">System Administration\/System Computing Services<\/option><option value=\"Truckee Meadows Community College\">Truckee Meadows Community College<\/option><option value=\"Western Nevada College\">Western Nevada College<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column is-half\">\n\t\t<p><label><strong>Contact Person's Name<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"contact-name\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Email<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"contact-email\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><label><strong>Phone<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"contact-phone\" \/><\/span><\/label>\n\t\t<\/p>\n\t\t<div class=\"transparency-text\">\n\t\t\t<p>NSHE System Administration provides administrative support to all public higher education institutions in Nevada. Our SMS messaging frequency will operate on a daily basis from 1 to 100 for all company members.\n\t\t\t<\/p>\n\t\t\t<p>By checking this box and providing your mobile number, you are agreeing to receive SMS messages from NSHE System Administration. Reply HELP for customer care contact information. Message frequency may vary and message and data rates may apply. You may reply \"STOP\" to unsubscribe at any time.\n\t\t\t<\/p>\n\t\t\t<p>To learn more view our full <a href=\"https:\/\/nshe.nevada.edu\/privacy\/\" target=\"_blank\">privacy statement<\/a> and review our <a href=\"https:\/\/nshe.nevada.edu\/sms-terms-and-conditions\/\" target=\"_blank\">SMS Terms and Conditions<\/a>.\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div id=\"contact-optin\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"contact-sms-consent\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"contact-sms-consent[]\" value=\"I consent to receiving text messages From NSHE and understand that message data rates may apply.\" \/><span class=\"wpcf7-list-item-label\">I consent to receiving text messages From NSHE and understand that message data rates may apply.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<h3>NSHE Driver's Information\n<\/h3>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><label><strong>Driver's Name<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-driver-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-driver-name\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Agency\/Department<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-agency-department\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-agency-department\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><label><strong>Office Address<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-driver-office-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-driver-office-address\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column is-half\">\n\t\t<p><label><strong>City<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-driver-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-driver-city\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>State<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-driver-state\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"nshe-driver-state\"><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Washington DC\">Washington DC<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\" selected=\"selected\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennslyvania\">Pennslyvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Zip Code<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-driver-zipcode\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-driver-zipcode\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column is-half\">\n\t\t<p><label><strong>Driver's License Number<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-driver-license-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-driver-license-number\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Issuing State<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-driver-license-state\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"nshe-driver-license-state\"><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Washington DC\">Washington DC<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\" selected=\"selected\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennslyvania\">Pennslyvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Expiration Date<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-driver-license-expiration-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-driver-license-expiration-date\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<h4>NSHE Vehicle Information\n<\/h4>\n<div class=\"columns\">\n\t<div class=\"column is-one-quarter\">\n\t\t<p><label><strong>EX Plate Number<\/strong><span class=\"screen-reader-text\"> for NSHE vehicle<\/span> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-vehicle-plate-num\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-vehicle-plate-num\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Vehicle ID Number (VIN)<\/strong><span class=\"screen-reader-text\"> for NSHE vehicle<\/span> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-vehicle-vin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-vehicle-vin\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Vehicle Mileage <\/strong><span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-vehicle-mileage\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-vehicle-mileage\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column is-one-quarter\">\n\t\t<p><label><strong>Year <\/strong><span class=\"screen-reader-text\"> for NSHE vehicle<\/span> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-vehicle-year\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-vehicle-year\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Make <\/strong><span class=\"screen-reader-text\"> for NSHE vehicle<\/span> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-vehicle-make\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-vehicle-make\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Model <\/strong><span class=\"screen-reader-text\"> for NSHE vehicle<\/span> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-vehicle-model\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nshe-vehicle-model\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns mb-0\">\n\t<div class=\"column\">\n\t\t<p><label for=\"nshe-vehicle-damage-description\"><strong>Describe damage to State Vehicle <\/strong><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-windshield-damage-only\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"nshe-windshield-damage-only[]\" value=\"Windshield damage only; no other party involved\" \/><span class=\"wpcf7-list-item-label\">Windshield damage only; no other party involved<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"nshe-vehicle-damage-description\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"nshe-vehicle-damage-description\" aria-invalid=\"false\" name=\"nshe-vehicle-damage-description\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<div role=\"radiogroup\" aria-labelledby=\"label-other-party-involved\">\n\t\t\t<p><label class=\"mt-0\" id=\"label-other-party-involved\"><strong>Was another driver involved in this accident?<\/strong> <span class=\"text-required\">(required)<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-party-involved\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"other-party-involved\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"other-party-involved\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div id=\"other-party-information\">\n\t<h3>Other Driver's Information\n\t<\/h3>\n\t<div class=\"columns\">\n\t\t<div class=\"column\">\n\t\t\t<div role=\"radiogroup\" aria-labelledby=\"label-self-insurance-card-provided\">\n\t\t\t\t<p><label id=\"label-self-insurance-card-provided\"><strong>Self-insurance card provided to driver\/owner?<\/strong><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-card-provided\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"insurance-card-provided\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"insurance-card-provided\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"columns\">\n\t\t<div class=\"column is-three-quarters\">\n\t\t\t<p><label><strong>Owner's Name<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column\">\n\t\t\t<p><label><strong>Phone <\/strong><span class=\"screen-reader-text\"> of other vehicle owner<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-phone\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"columns\">\n\t\t<div class=\"column\">\n\t\t\t<p><label><strong>Owner's Street Address <span class=\"screen-reader-text\"> of other vehicle owner<\/span><\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"columns\">\n\t\t<div class=\"column is-half\">\n\t\t\t<p><label><strong>City<\/strong> <span class=\"screen-reader-text\"> of other vehicle owner<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-city\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column\">\n\t\t\t<p><label><strong>State<\/strong> <span class=\"screen-reader-text\"> of other vehicle owner<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-state\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"other-owner-state\"><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Washington DC\">Washington DC<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\" selected=\"selected\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennslyvania\">Pennslyvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column\">\n\t\t\t<p><label><strong>Zip Code<\/strong> <span class=\"screen-reader-text\"> of other vehicle owner<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-zipcode\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-zipcode\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"columns\">\n\t\t<div class=\"column\">\n\t\t\t<p><label><span class=\"screen-reader-text\">Owner's<\/span> <strong>Insurance Company<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-insurance-company\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-insurance-company\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"columns\">\n\t\t<div class=\"column is-half\">\n\t\t\t<p><label><span class=\"screen-reader-text\">Owner's Insurance<\/span> <strong>Policy Number<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-insurance-policy-num\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-insurance-policy-num\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column\">\n\t\t\t<p><label><span class=\"screen-reader-text\">Owner's Insurance Policy <\/span> <strong>City<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-insurance-policy-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-insurance-policy-city\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column\">\n\t\t\t<p><label><span class=\"screen-reader-text\">Owner's Insurance Policy <\/span><strong>State<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-insurance-policy-state\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"other-owner-insurance-policy-state\"><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Washington DC\">Washington DC<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\" selected=\"selected\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennslyvania\">Pennslyvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"columns\">\n\t\t<div class=\"column is-three-quarters\">\n\t\t\t<p><label><span class=\"screen-reader-text\">Owner's<\/span> <strong>Insurance Agent<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-insurance-agent\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-insurance-agent\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column\">\n\t\t\t<p><label><span class=\"screen-reader-text\">Insurance Agent's <\/span> <strong>Phone<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-owner-insurance-agent-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-owner-insurance-agent-phone\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"columns\">\n\t\t<div class=\"column\">\n\t\t\t<div role=\"radiogroup\" aria-labelledby=\"label-driver-different-from-owner\">\n\t\t\t\t<p><label class=\"mt-0\" id=\"label-driver-different-from-owner\"><strong>Is the driver in the other vehicle different from the owner of the vehicle?<\/strong><\/label>\n\t\t\t\t<\/p>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"driver-different-from-owner\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"driver-different-from-owner\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"driver-different-from-owner\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div id=\"other-driver-information\">\n\t\t<div class=\"columns\">\n\t\t\t<div class=\"column is-three-quarters\">\n\t\t\t\t<p><label><strong>Driver's Name<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-driver-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-driver-name\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column\">\n\t\t\t\t<p><label><strong>Phone <\/strong><span class=\"screen-reader-text\"> of other vehicle's driver<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-driver-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-driver-phone\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"columns\">\n\t\t\t<div class=\"column\">\n\t\t\t\t<p><label><strong>Driver's Street Address <span class=\"screen-reader-text\"> of other vehicle owner<\/span><\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-driver-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-driver-address\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"columns\">\n\t\t\t<div class=\"column is-half\">\n\t\t\t\t<p><label><strong>City<\/strong> <span class=\"screen-reader-text\"> of other driver<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-driver-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-driver-city\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column\">\n\t\t\t\t<p><label><strong>State<\/strong> <span class=\"screen-reader-text\"> of other driver<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-driver-state\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"other-driver-state\"><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Washington DC\">Washington DC<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\" selected=\"selected\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennslyvania\">Pennslyvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column\">\n\t\t\t\t<p><label><strong>Zip Code<\/strong> <span class=\"screen-reader-text\"> of other vehicle driver<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-driver-zipcode\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-driver-zipcode\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"columns\">\n\t\t<div class=\"column is-half\">\n\t\t\t<p><label><strong>Other Driver's License Number<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-driver-license-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-driver-license-number\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column\">\n\t\t\t<p><label><strong>Issuing State<\/strong> <span class=\"screen-reader-text\"> for other driver's license<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-driver-license-state\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"other-driver-license-state\"><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Washington DC\">Washington DC<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\" selected=\"selected\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennslyvania\">Pennslyvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column\">\n\t\t\t<p><label><strong>Expiration Date<\/strong> <span class=\"screen-reader-text\"> for other driver's license<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-driver-license-expiration-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-driver-license-expiration-date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h4>Other Vehicle Information\n\t<\/h4>\n\t<div class=\"columns\">\n\t\t<div class=\"column\">\n\t\t\t<p><label><strong>Describe <\/strong><strong>damage<\/strong> to other vehicle and any <strong>injuries<\/strong> reported <br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-vehicle-damage-description\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"other-vehicle-damage-description\"><\/textarea><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<h3>Details of Accident\n<\/h3>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><label><strong>Date of Accident<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"accident-date\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Time of Accident<\/strong> <span class=\"text-required\">(required)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-time\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"accident-time\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><label><strong>Street Address where accident occurred<span class=\"screen-reader-text\"> of other vehicle owner<\/span><\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"accident-address\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column is-half\">\n\t\t<p><label><strong>City <\/strong> <span class=\"screen-reader-text\"> where accident occurred<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"accident-city\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>State<\/strong> <span class=\"screen-reader-text\"> where accident occurred<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-state\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"accident-state\"><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Washington DC\">Washington DC<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\" selected=\"selected\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennslyvania\">Pennslyvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Zip Code<\/strong> <span class=\"screen-reader-text\"> where accident occurred<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-zipcode\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"accident-zipcode\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><label><strong>Explain What Happened<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-explanation\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"accident-explanation\"><\/textarea><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column is-three-quarters\">\n\t\t<p><label><strong>Accident Reported to (<em>NHP, Campus Police, or local law enforcement<\/em>)<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-reported\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"accident-reported\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label><strong>Report #<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-report-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"accident-report-number\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<div role=\"radiogroup\" aria-labelledby=\"accident-citations-issued\">\n\t\t\t<p><label id=\"accident-citations-issued\"><strong>Citations Issued?<\/strong><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-citations-issued\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"accident-citations-issued\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"accident-citations-issued\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><label><strong>If \"Yes,\" explain<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accident-explain-citation\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"accident-explain-citation\"><\/textarea><\/span><\/strong><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns mb-0\">\n\t<div class=\"column\">\n\t\t<p><label for=\"accident-witnesses\"><strong>Witnesses (Please include Name, Address, and Phone Number)<\/strong><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"accident-witness-card-given\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"accident-witness-card-given[]\" value=\"Witness card given\/statement taken\" \/><span class=\"wpcf7-list-item-label\">Witness card given\/statement taken<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"accident-witnesses\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"accident-witnesses\" aria-invalid=\"false\" name=\"accident-witnesses\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns mb-0\">\n\t<div class=\"column\">\n\t\t<p><label><strong>Persons Injured<\/strong> (If injured person is a NSHE Employee, complete a Worker\u2019s Compensation Claim Form.)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"persons-injured\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"persons-injured\"><\/textarea><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns\">\n\t<div class=\"column\">\n\t\t<p><label><strong>Please attach any supporting documents, including damage estimates and diagrams of the accident <\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"supporting-documents\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.jpg,.jpeg,.png,.gif,.ppt,.pptx,.avi,.ogg,.m4a,.mov,.mp3,.mp4,.mpg\" aria-invalid=\"false\" type=\"file\" name=\"supporting-documents\" \/><\/span><br \/>\n<em>(Please note: Documents must not exceed 5MB in size)<\/em><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<\/div>\n        <\/div>\n    <\/div>\n\n    \n\n\n<script 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