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Vehicle Accident Report TC-3 - Nevada

Vehicle Accident Report Form. This is a Nevada form and can be used in Office Of Attorney General Statewide .
 Fillable pdf Last Modified 6/9/2005
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State of Nevada For State Use Only: State Claim No. __________ VEHICLE ACCIDENT REPORT Budget Acct. No. _________ Coverage _______________ INSTRUCTIONS: (If you need more space, attach a separate sheet of paper) Adjuster ________________ " Complete as much information as possible at the scene. REPORT all accidents involving third parties, whether or not there is damage or injury. Cooperate with investigating office r(s) and the States adjuster(s). Notify Attorney Generals Office ASAP if there is an injury. Tel.: (775) 684-1263; Fax: (775) 684-1275 Sent original to AGs Office Claims Manager, Office of the Attorney General, WITHIN 48 HOURS 100 N. Carson Street, Carson City, NV 89701 Sent copy to Risk Management Risk Management, 201 S. Roop Street, Suite 201, WITHIN 48 HOURS Carson City, NV 89701 A.M. Location of Date of Accident ______________ Time ________ P.M. Accident _______________________ OUR INFORMATION: Drivers Name _______________________________ Agency ______________________________ Office Address ___________________________________________ Bus. phone ______________ Drivers Lic. No. ___________________________ State__________ Expiration Date ____________ Contact Person __________________________ Title ________________ Phone ______________ Is this a MOTOR POOL vehicle? Yes No Vehicle ID No.(VIN) _____________________ Plate No. ____________ Year _______ Make _________________ Model ____________________ Location of Vehicle ________________________________________________________________________________ Describe damage to State vehicle: Windshield damage only; no other party involved ________________________________________________________________________________ THEIR INFORMATION: Self-insurance card provided to driver/owner? Yes No OWNERS NAME _____________________________________ Daytime Phone _______________ Address _______________________________________ City/State/Zip ______________________ Insurance Company ____________________ Policy No. ______________ City/State ____________ Insurance Agent ______________________________________ Phone No. ___________________ Plate No. _____________ State ______ Year _____ Make _________ Model __________________ DRIVERS NAME ___________________________________ Daytime Phone _________________ Address ________________________________________City/State/Zip _____________________ Drivers Lic. No. ___________________________ State ________ Expiration Date _____________ Describe damage to other vehicle and any injuries reported __________________________________ ________________________________________________________________________________ TC-3 (revision of RSK-001, 4/04) <<<<<<<<<********>>>>>>>>>>>>> 2Office of the Attorney General EXPLAIN WHAT HAPPENED : ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Accident Reported to (NHP, Metro, Reno P.D., etc.) ______________________ Report # _________ Citations Issued? No Yes If Yes, explain _______________________________________ Complete the following diagram showing direction and positions of automobiles involved. Clearly designate point of contact. Indicate by arrow the direction of NORTH . path before accident - - - - - - path after accident ++++++ Railroad Stop Sign { Stop Light Pedestrian WITNESSES: Witness card given/statement taken Name Address Phone PERSONS INJURED: (If injured person is a State Employee, complete a Workers Compensation Claim Form.) Name Address Phone Agency Information: Damage estimates attached Estimates will follow State Drivers Signature _______________________________________ Date ________________ Reviewed by Safety Coordinator ________________________________ Date ________________ Reviewed by Department Head _________________________________ Date ________________
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