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Vehicle # Employee Name Department Job Title Date of Occurrence Time Time am/pm am/pm Exact location of occurrence Describe accident or occurrence in detail Year Make Model Vehicle # VIN (Vehicle ID Number) Plate # In detail list vehicle damage Did a law enforcement agency investigate? Case # Witness Name Phone # Witness Name Phone # Responsible person/driver for damage Gender M / F Address Phone Driver License # State Vehicle Owner Name Address Phone Year Make Model Plate # Year/State Name of Insurance Company Agency Policy # Fitness for Duty Policy Administered? Yes No If not, why? One copy to Fleet Employee Signature Date One copy to Risk Management Immediate Supervisor Date One copy to Department Division or Dept. Head Date Fleet Use Only Fleet Personnel Y / N Date Received Y / N Work Order # Were Pictures taken? If yes, list agency Date Reported OGDEN CITY VEHICLE DAMAGE REPORT Name of Investigating Officer Received within 48 Hours? Witnesses 3rd Party Information Fitness for Duty MUST BE COMPLETED AND RETURNED WITH VEHICLE TO FLEET DIVISION WITHIN 48 HOURS OF DAMAGE. Work Phone Supervisor Name Division Employee Information Occurrence Information Vehicle Damage Description