NOTICE OF CLAIM
Automobile/Equipment Accident Report
Last Revised: 12/02/08

Departments must report loss of University property due to an automobile or motorized equipment (similar to a motorized vehicle) accident to the Department of Safety and Risk Services, 137 Onate Hall, as soon as practical after the occurrence. Complete both sides of this form and attach:

• a copy of the police report, if applicable;
• a copy of the purchase document as proof of ownership, purchase, and value; and
• an estimate of the loss, listing the vendor and replacement or repair cost of each item.

Automobile accidents must also be reported to the UNM Police Department.

Police Report Filed: Yes ______ No____ If yes, indicate agency (i.e. UNMPD, APD, other)
___________________________________________________________________________

Department_____________________________________ Organization Code ____________

UNM Automobile Information:

Name of Driver___________________ Work & Home Phone Number(s)___________________

SSN____________________ Driver's License #/State ________________________

Vehicle #____________License Plate #____________ Year ____Make_______ Model_______

Serial # _______________

Date & Time of Accident______________________________________________________

Location of Accident _________________________________________________________

Location of Damage on Vehicle___________________Can Vehicle Be Driven: Yes___No___

Citations Issued (for what?) ____________________________________________________

Names of All Passengers in the Vehicle (if none, write none) _____________________________
___________________________________________________________________________

Names of All Injured in UNM Vehicle ____________________________________________

Banner Index to which vehicle insurance is charged  _____________________________

UNM Driver's Account of Accident: _____________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Other Party:

Name of Other Driver, Property Owner, or Pedestrian________________________________

Drivers License #/State ______________________________________

Address/City/State/Zip________________________________________________________

Daytime Phone # _______________ Nighttime Phone # ______________

License Plate # _________Year ____ Make_______Model ________

Location of Damage on Vehicle_________________Can Vehicle Be Driven: Yes___ No___

Citations Issued (for what) ______________________________________________________

Insurance Company/Policy Number _____________________________________________

__________________________________________________________________________
Names of All Passengers in the Vehicle (if none, write none)

__________________________________________________________________________
Names, Addresses, and Phone Numbers of All Those Injured in Other Vehicle

Other Party's Account of Accident: ______________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 Comments may be sent to UBPPM@UNM.edu
http://www.unm.edu/~ubppm