INSURED
NAME & ADDRESS
THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
C/O THE STATE OF NORTH CAROLINA
RISK MANAGEMENT SERVICES
104 AIRPORT DRIVE, CAMPUS BOX 1100
CHAPEL HILL, NC 27599-1100 / UNC CONTACT
Janet Hoernke / PHONE
(919) 962-6681
(919) 962-0636 (fax) / UNC CLAIM NO.
For Internal Use
COMPANY
The Travelers / POLICY NO.
TRJCAP-104T6800 or
660-826F2846 / LOSS RUN CODE
For Internal Use
LOSS DETAILS
LOCATION OF ACCIDENT / DATE & TIME OF LOSS / AUTHORITY CONTACTED & REPORT NO. / VIOLATIONS / CITATIONS
DESCRIPTION OF ACCIDENT
STATE OPERATED VEHICLE & DRIVER INFORMATION
VEH. NO. / YEAR, MAKE, MODEL / V.I.N. (Vehicle Identification) / PLATE NO. / UNC-OWNED RENTAL MOTOR FLEET OTHER
DRIVER'S NAME & HOME ADDRESS / PHONE
DATE OF BIRTH / DRIVER'S LICENSE NO. / PURPOSE OF USE / USED WITH PERMISSION?
DRIVER'S UNC DEPT. / UNC DEPT. NO. / PHONE / SUPERVISOR
DESCRIBE DAMAGE / ESTIMATE AMOUNT / WHERE VEHICLE CAN BE SEEN / WHEN?
PROPERTY DAMAGED
DESCRIBE PROPERTY (If auto, year, make, model, plate no. and color) / INSURANCE OR AGENCY NAME & POLICY NO.
OWNER'S NAME & ADDRESS / BUSINESS PHONE / RESIDENCE PHONE
OTHER DRIVER'S NAME & ADDRESS (Check if same as owner) / BUSINESS PHONE / RESIDENCE PHONE
DESCRIBE DAMAGE / ESTIMATE AMOUNT / WHERE VEHICLE CAN BE SEEN? / WHEN?
INJURED
NAME & ADDRESS / PHONE / UNC VEHICLE, OTHER VEHICLE OR PEDESTRIAN? / EXTENT OF INJURY
WITNESSES OR PASSENGERS
NAME & ADDRESS / PHONE / UNC VEHICLE, OTHER VEHICLE OR PEDESTRIAN? / EXTENT OF INJURY
ADDITIONAL COMMENTS
REPORTED BY / SIGNATURE OF STATE OPERATED VEHICLE DRIVER
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