UNIVERSITY CLAIM
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WINDSHIELD LOSS REPORT
STATE Department Division Section AFIS Mail Code RMS NO. (for RMS use only)
AGENCY U of A 412
ACCIDENT Street Address
LOCATION
Intersecting Street of Highway No. and Mile Post No. ( Intersection
( Non-Intersection
CITY ( Inside County Weather
( Outside
DATE OF ACCIDENT Day of Week Hour A.M. No. of Vehicles Involved No. Persons Injured
P.M 1 0
MOTOR VEHICLE 1. ( Pedestrian 3. ( Other State Vehicle 5. ( Other
INVOLVED WITH 2. ( Other Motor Vehicle 4. ( Fixed Object
Year Make Model License No. State
UA Vehicle No. Department Department/ Number
Motor Pool Vehicle?
Last Name First M.I. Point of Impact on Vehicle Est. Cost Repair
Address City, State Zip Phone(s)
Job Classification Department/Division/Section Drivers License No. ( Operator Exp. Date State
( Chauffeur
Name Address Phone
Name Address Phone
POLICE Agency Officer and I.D. No. Report No.
REPORT
IMPORTANT: DESCRIBE HOW ACCIDENT OCCURRED:
I hereby certify that this is a true statement of the facts to the best of my knowledge and belief. ( Phone
( In Person
( Mail
X
Driver’s Signature
Reported by Phone # Date
SUPERVISOR NAME (Print or Type) (INT) PHONE # DATE
MAIL COMPLETED FORM TO: Risk Management, PO Box 210300, Tucson, Arizona 85721-0300 or FAX 626-0905
-----------------------
FACTS
STATE VEHICLE
DRIVER
WITNESSES
................
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