VEHICLE ACCIDENT REPORT - SISC
| |SELF-INSURED SCHOOLS OF CALIFORNIA |ORIGINAL TO: DISTRICT OFFICE |
|VEHICLE ACCIDENT REPORT |(SISC II) |COPY TO: SISC II |
| |**CONFIDENTIAL INFORMATION** |PO BOX 1847 |
| |DO NOT RELEASE TO OTHER PARTIES |BAKERSFIELD CA 93303-1847 |
|DISTRI|DRIVER'S NAME |DOB/AGE |JOB TITLE |
|CT | | | |
|VEHICL| | | |
|E AND | | | |
|DRIVER| | | |
| | | | |
| |DRIVER'S LICENSE NO. |ACCIDENT DATE |HOME ADDRESS |
| | | | |
| |DESCRIBE DAMAGE TO VEHICLE |HOME PHONE | | |
| | |BUSINESS PHONE | | |
| | | | |
| | |SCHOOL DISTRICT/OWNER |DISTRICT VEHICLE NO. |
| | | | |
| | | | |
| |MANDATORY INFORMATION: VEHICLE LICENSE NO., YEAR, MAKE, MODEL, VIN # |ADDRESS, CITY, STATE |
| | | |
| |WAS VEHICLE BEING USED ON OFFICIAL BUSINESS? | |
| |YES NO (If no, attach explanation) | |
| | | |
|ACCIDE|ACCIDENT LOCATION (Address/Area) |ROAD CONDITIONS |
|NT | | |
|DETAIL| | |
|S | | |
| | | |
| | | |
| | |WEATHER CONDITIONS |
| | | |
| |CITY/STATE |TRAFFIC CONDITIONS |
| | | |
| |COUNTY |HOW FAST WERE YOU DRIVING? |ESTIMATED SPEED OF OTHER VEHICLE | |
| | | | | |
| |POLICE REPORT COMPLETED |NAME & ADDRESS OF INVESTIGATING AGENCY |
| | YES NO | |
| |AGENCY: CHP PD OTHER |OFFICER'S NAME & BADGE NO: | |
|OTHER |DRIVER'S NAME |DOB/AGE |VEHICLE LICENSE NO. |VEHICLE YEAR, MAKE, MODEL |
|VEHICL| | | | |
|E | | | | |
| | | | | |
| |DRIVER'S LICENSE NO. |HOME PHONE |WORK PHONE |REGISTERED OWNER |
| | | | | |
| |DRIVER'S ADDRESS, CITY, ST, ZIP |OWNER'S ADDRESS, CITY, ST, ZIP |HOME PHONE NO. | |
| | | |WORK PHONE NO. | |
| | | | |
| |BRIEFLY DESCRIBE DAMAGES TO OTHER VEHICLE OR PROPERTY |NAME & ADDRESS OF OTHER PARTY'S INSURANCE |
| | | |
| | | |
|INJURE|NAME |PHONE |ADDRESS, CITY, ST, ZIP |
|D | | | |
| | | | |
| | | | |
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| | | | |
|WITNES|NAME |PHONE |ADDRESS, CITY, ST, ZIP |
|S | | | |
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| | | | |
| | | | |
|PASSEN|NAME |PHONE |ADDRESS, CITY, ST, ZIP |
|GERS | | | |
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Vehicle Accident Report.doc Form 2009VA1
|( VEHICLE ACCIDENT REPORT ( |( CONFIDENTIAL INFORMATION ( |
|DO NOT RELEASE TO OTHER PARTIES |
|ACCIDENT|FULLY STATE HOW ACCIDENT OCCURRED (Give details, attach additional sheets if necessary) |
|DETAILS | |
|- | |
|DESCRIPT| |
|ION | |
| |Date of Accident: | |
| | |
|ACCIDENT| |
|DETAIULS| |
|- | |
|DIAGRAM | |
|ADDITION|DRIVER'S NAME |AGE/DOB |VEHICLE LIC. NO. |VEHICLE YEAR, MAKE, MODEL |
|AL | | | | |
|VEHICLES| | | | |
|/PASSENG| | | | |
|ER(S) | | | | |
|Passenge| | | | |
|r | | | | |
|Inured | | | | |
| | | | | |
| |DRIVER'S LICENSE NO. |HOME/BUSINESS TEL. NO. |REGISTERED OWNER |
| | | | |
| |ADDRESS, CITY, STATE, ZIP |REGISTERED OWNER ADDRESS, CITY, STATE, ZIP |
| | | |
| |BRIEFLY DESCRIBE DAMAGES TO OTHER VEHICLE OR PROPERTY |HOME/BUSINESS TEL. NO. |
| | | |
| | |NAME & ADDRESS OF OTHER PARTY'S INSURANCE |
| | | |
| |NAME |ADDRESS, CITY, STATE, ZIP |PHONE NO. |
| | | | |
| |NAME |ADDRESS, CITY, STATE, ZIP |PHONE NO. |
| | | | |
| |NAME |ADDRESS, CITY, STATE, ZIP |PHONE NO. |
| | | | |
| |NAME |ADDRESS, CITY, STATE, ZIP |PHONE NO. |
| | | | |
Statement:
The answers in this report contain a true full account of the accident.
Employee Signature Date Reviewing Supervisor Signature Date
-----------------------
Indicate Points
of Compass
N.S.E.W.
1
2
Number District vehicle as 1, other vehicle(s) as 2,3,etc. Show Pedestrian(s) by o
Show direction of travel as follows:
Before accident
After accident
Give names to streets and roads
................
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