Research Corporation of the University of Hawaiʻi

STATE OF HAWAII AUTOMOBILE LOSS NOTICE
1. DATE OF LOSS: ______/______/______
3. POLICE REPORT #: ________________________
5. DIVISION: ______________________________
7. ACCIDENT LOCATION: Street Names, Address, City, State: ______________________________________ _________________________________________________________________________________________ 8. ACCIDENT DESCRIPTION: _________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 9. PURPOSE OF TRIP AT TIME OF ACCIDENT: ___________________________________________________ _________________________________________________________________________________________
2. TIME OF LOSS: _______________ AM PM 4. DEPARTMENT: _____________________________ 6. BRANCH: _________________________________
(If damage is to a vehicle rented to a State employee, input the information on the vehicle rented to the State employee here)
Year: __________ Make: ____________________ Model: ______________________________ VIN: ______________________________________ License Plate #: _______________________ Describe Damage to State Vehicle: __________________________________________________ _______________________________________________________________________________
STATE VEHICLE
Estimated Damage Amount: $ _________________________
Driver Name: ___________________________________ Work Phone:____________________ State Work Place/Location:________________________________________________________ Driver Position Title: ____________________________ Home/Cell #: _____________________ Driver Email: ___________________________________________________________________ Did you have permission to drive this vehicle: YES NO
Name of the person who gave you permission:_______________________________________
STATE DRIVER INFO
Provide that person’s work phone number: __________________________________________
Driver Name: ___________________________________ Phone #:________________________ Address: ___________________________________City: _______________St: ___ Zip: _______ Email: ______________________________________ Is the Driver the Owner? YES NO
OTHER
DRIVER INFO (IF APPLICABLE)
Note: if the driver was not the owner, provide the owner (or rental car company) info below:
Owner Name: ___________________________________ Phone #:________________________ Address:____________________________________City: _______________St: ___ Zip: _______ Owner Email: __________________________________________________
OWNER’S INFO
Form RMA-001 (08/14) P. 1 of 2
AUTOMOBILE LOSS NOTICE – PAGE 2
Year: __________ Make: ____________________ Model: ______________________________ VIN: ____________________________________ License Plate #: ________________________ Describe Damage to Other Vehicle: __________________________________________________ _______________________________________________________________________________ Estimated Damage Amount: $ _________________________
OTHER VEHICLE INFO
PROPERTY DAMAGE (if other than a vehicle)
Insurance Carrier: ___________________________ Policy #: _____________________________
Owner Name: __________________________________ Phone #: ________________________ Description of Property: __________________________________________________________ Describe Damage: _______________________________________________________________
____________________________ __________________________________________________
WITNESSES
Name Address Telephone
____________________________ ____________________________ ____________________ ____________________________ ____________________________ ____________________
____________________________ ____________________________ ____________________
PASSENGERS IN STATE VEHICLE
Name Address Telephone
____________________________ ____________________________ ____________________ ____________________________ ____________________________ ____________________
____________________________ ____________________________ ____________________
Any additional information to provide? ______________________________________________ _______________________________________________________________________________
ADDITIONAL INFO
_______________________________________________________________________________
STATE DRIVER’S SIGNATURE: __________________________________
SUPERVISOR’S SIGNATURE: ___________________________________ SUPERVISOR PRINT NAME: ___________________________________ SUPERVISOR TITLE: ___________________________________________________ SUPERVISOR EMAIL: __________________________________________________
DATE SIGNED: _____/_____/_____
DATE SIGNED: _____/_____/_____ PHONE #: ____________________
Form RMA-001 (08/14) P. 2 of 2