DISTRICT VEHICLE

DRIVER LICENSE # VEHICLE YR & MAKE VEHICLE LICENSE # AREA OF DAMAGE

DIAGRAM & MISCELLANEOUS (IF NECESSARY)

TRI COUNTY SCHOOLS INSURANCE GROUP AUTO CLAIMS DEPARTMENT 10565 BRUNSWICK ROAD, SUITE 11 GRASS VALLEY, CA 95949 530-274-7213 PHONE 530-273-6459 FAX

INDICATE ON THIS DIAGRAM WHAT HAPPENED

SCHOOL DISTRICT:

DESCRIBE HOW ACCIDENT OCCURRED

REPORT OF ACCIDENT
1. Stop at once. 2. Provide assistance to any injured party. 3. Contact the local police authority. 4. Phone your supervisor if there is personal injury or extensive property damage. 5. Do not discuss the accident with anyone other than the police authority, our employer or a representative of the JPA. 6. Complete this report as soon as possible.

Indicate North By Arrow

LIABILITY COVERAGE
THIS VEHICLE IS OWNED BY A PUBLIC ENTITY AND IS SELF-INSURED THROUGH THE MEMBERSHIP IN A JOINT POWERS INSURANCE AUTHORITY PURSUANT TO THE CALIFORNIA GOVERNMENT CODE.

INJURED SCHOOL DISTRICT ACCIDENT DATE LOCATION POLICE AGENCY CALLED PHONE: OTHER PARTY HOME WORK NATURE OF INJURY NAME ADDRESS NAME ADDRESS AGE NAME ADDRESS PHONE: HOME WORK TIME NAME ADDRESS AGE NAME ADDRESS

WITNESSES

PHONE:

HOME WORK

PHONE:

HOME WORK

PHONE:

HOME WORK

DRIVERS LIC.# AUTOMOBILE YR & MAKE

NATURE OF INJURY NAME ADDRESS AGE NAME ADDRESS

LICENSE NUMBER AREA OF DAMAGE PHONE: HOME WORK PRIOR DAMAGE NATURE OF INJURY NAME INSURANCE COMPANY ADDRESS PHONE: TELEPHONE NUMBER NUMBER OF PASSENGERS HOME WORK NATURE OF INJURY PHONE: HOME WORK ADDRESS AGE NAME ADDRESS PHONE: HOME WORK