Douglas County Human Resources Department

Notice of Loss/Accident
(print or type)

TYPE OF LOSS:

Auto

Liability

Property

INSURED:

Douglas County Risk Management
P.O. Box 218, Minden, NV 89423

Claim Number: _______________________
Person to Contact: _____________________
Phone: _______________________

Department: _________________________________________________

LOSS: _______________________________________

Date and Time: _______________________________________________

Location: _______________________________________________________

Description of Loss:

__________________________________________________________________

MOTOR VEHICLE ACCIDENT:

Employee's Vehicle, Year and Model

__________________________________________________________________

License Number: #_______________________________________________________

Vehicle ID Number: #_______________________________________________________

Driver's License Number: #_______________________________________________________

Driver's Age: _______

Residence Phone : #(____)_____________________________

Business Phone : #(____)_____________________________

Description of Loss:

__________________________________________________________________

PROPERTY DAMAGE:

Describe Property (If auto - year, make, model, license number)

__________________________________________________________________

Company Name:__________________________________________________________________

Owner's Name:__________________________________________________________________

Address: __________________________________________________________________

Residence Phone : #(____)_____________________________

Business Phone : #(____)_____________________________

Driver's Name:__________________________________________________________________

Address: __________________________________________________________________

Residence Phone : #(____)_____________________________

Business Phone : #(____)_____________________________

Description of Damage:

__________________________________________________________________

Estimate Amount: $___________

Where can property be seen?_______________________

INJURED:

(1.)

Name and Address:

__________________________________________________________________

Phone : #(____)_____________________________

Hospital/Doctor : ________________________________________________

Nature of Injury : ________________________________________________

(2.)

Name and Address:

__________________________________________________________________

Phone : #(____)_____________________________

Hospital/Doctor : ________________________________________________

Nature of Injury : ________________________________________________

WITNESSES OR PASSENGERS:

(1.)

Name and Address:

__________________________________________________________________

Phone : #(____)_____________________________

Nature of Injury : ________________________________________________

(2.)

Name and Address:

Phone : #(____)_____________________________

Nature of Injury : ________________________________________________

POLICE INVOLVED: Yes( ) No( ) Agency : ________________________________________________

Officer : ________________________________________________

Report Number : #________________________________________________

LIABILITY:

Alleged Offense : ________________________________________________

Officials Involved : ________________________________________________

Claimant - Name & Address:

__________________________________________________________________

Residence Phone : #(____)_____________________________

Business Phone : #(____)_____________________________

Remarks : ________________________________________________

Date : ________________________________________________

Reported By : ________________________________________________

Reported To : ________________________________________________

Douglas County Risk Management (702) 782-9860

DESCRIBE HOW THE ACCIDENT HAPPENED:

Weather : ________________________________________________

Road Conditions : ________________________________________________

Your Speed : ________________________________________________

DESCRIPTION OF THE ACCIDENT AND SEQUENCE OF EVENTS LEADING TO THE ACCIDENT:

__________________________________________________________________

DIAGRAM: Fill in name of streets, loacte vehicles, indicate direction of travel:

PERSON SUBMITTING REPORT:

Name : ________________________________________________

Title : ________________________________________________

Department : ________________________________________________

Phone : ________________________________________________

Date : ________________________________________________

Please print or type clearly.
Attach all completed forms/photos/invoices.
Forward to Risk Management within 48 hours.

VEHICLE COLLISION REVIEW
To be completed by Supervisor
(please print or type)

Name of Employee : ________________________________________________

Date of Accident : ________________________________________________

Type of Collision:

Vehicle Ahead ( ) - Vehicle Behind ( ) - Backing ( ) - Animal ( ) - Side Swipe ( ) -

Bicycle ( ) - Pedestrian ( ) - With Fixed Object ( ) - Run-Off Road ( ) - Head On ( )

Other : ________________________________________________

Did our driver violate a traffic regulation? : Yes ( ) - No ( )

Was our driver given a citation by police? : Yes ( ) - No ( )

In your opinion, what caused the collision? :

__________________________________________________________________

Did our driver claim that any malfuntioning or defective vehicle component(s) caused the collision?: Yes ( ) - No ( )

Were any of the following conditions less than good at the time of the collision?:

Traffic ( ) - Weather ( ) - Light ( ) - Road ( )

Other : ________________________________________________

What was the condition of the driver?: Normal ( ) - Fatigued ( ) - Sick ( ) - Intoxicated ( )

Was the dirver tested for drug & alcohol?: Yes ( ) - No ( )

Location of testing? : ________________________________________________

Other : ________________________________________________

___________________________________________________________

Was the collision preventable? Yes ( ) - No ( )

(Preventable defined as: an accident in which the driver in questions failed to do everything he/she reasonably could have done to prevent the accurrence.)

If preventable, what corrective action do you recommend to prevent a furture occurrence of the same type?

___________________________________________________________

Was disciplinary action taken against the driver? Yes ( ) - No ( )

Print name of supervisor:

___________________________________________________________

Division : ___________________________________________________________

Signature of supervisor:

___________________________________________________________

Date : ___________________________________________________________

Please print or type clearly.
Attach all completed forms/photos/invoices.
Forward to Risk Management within 48 hours.

Douglas County Human Resources
1594 Esmeralda Avenue
P.O. Box 218
Minden, NV 89423
Phone: 775.782.9860 - Fax: 775.782.9083 - Job Line 775.782.9824
e-mail: recruitment@co.douglas.nv.us