Automobile Loss Notice
	Member Section Supervisory Union SU Contact Phone choose one Addison Central Addison Northeast Addison Northwest Addison Rutland Barre Battenkill Valley Blue Mountain Colchester Franklin Central Franklin Northeast Franklin West Lamoille North Montpelier Orange East Orange North Orange Southwest Orange Windsor Orleans Central Orleans Southwest Orleans-Essex North Patricia A. Hannaford Career Center River Valley Technical Center Rutland Central Rutland Northeast Rutland South Rutland Southwest South Burlington Springfield Washington Northeast Washington West Windham Northeast Windsor Central Windsor Southeast Windsor Southwest Winooski () -   SU Contact Person SU Contact Email Loss Section: Date of accident Location of Accident Description of Accident Did authorities investigate? Yes   No If Yes, please list name of police dept. Please list any violations/citations given Vehicle (involved in accident): Make Model Year VIN# Driver of vehicle involved in accident Driver's relationship to member (employee/volunteer, etc.) Is this vehicle owned/leased by the SU/school? Yes   No Was vehicle used with member's permission? Yes   No Have you received a copy of the accident report? Yes   No Property Damage: School Vehicle/Property: Describe the damage (if any) Estimated amount of damage (if any) Describe any other property damaged Other Vehicle/Property: Were other vehicles damaged? Yes   No Injured Parties: Were there injuries to vehicle occupants? Yes   No Other: Were there any witnesses to the accident? Yes   No Important information regarding the above: If the answer to any of the previous questions is YES, the adjuster most likely will be requesting the following information. Your assistance in compiling these items will greatly assist in the adjustment of this claim. If you answered YES to the question, "Were other vehicles damaged?", each vehicle's: Make Model Year Vehicle Identification Number (VIN) Driver of vehicle Address/phone number of other driver Insurance carrier of other driver Description of damage Damage to any collateral property (buildings, guardrails, etc.) If you answered YES to the question, "Were there injuries to vehicle occupants?", each occupant's: Name/Address/Age Vehicle traveling in Injuries If you answered YES to the question, "Were there witnesses to the accident?", each witness's: Name Address Phone number This notice was submitted by: on:
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