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Vehicle Accident Reporting Form

Please use this form to report accidents involving vehicle OWNED by the City of Charlotte or Mecklenburg County or Charlotte-Mecklenburg Schools.
 
Call Risk Management @ 704-336-3301 immediately fo bodily injury or serious property damage is involved. This written report should be sent within 24 hours (one business day) of the occurance.
 
*Denotes Required Fields
 
Organization Information
Organization*
Department*
Division*
Department Code
Called to Risk Mangement By
Police Report Number
Zone-Solid Waste Services Only
 
Our Driver - Vehicle Information
Date and Time of Accident*
Address*
Driver*
Work Telephone*
Employee Number*
Driver's License Number
Tag Number*
Unit Number*
Year and Make*
Part Damaged
Estimated Property Damage in dollars
Driver Description of Accident*
If applicable, were emergency lights and/or sirens in use?*
Not Applicable
Yes
No
Was the Driver injured?*
Yes
No
If Yes, where was the Driver taken for medical care?*
 
Passenger 1 Information
Name
Telephone Number
Address
City-State-Zip
Was this person injured?
Yes
No
If Yes, where was this Passenger taken for medical care?
 
Passenger 2 Information
Name
Telephone Number
Address
City-State-Zip
Was this person injured?
Yes
No
If Yes, where was this Passenger taken for medical care?
 
Other Vehicle Information
Driver's Name
Address
City-State-Zip
Telephone Number
Driver's License Number
Owner's Name
Owner's Address
Owner's City-State-Zip
Owner's Telephone Number
Was this person injured?
Yes
No
If Yes, where was this Driver taken for medical care?
 
Other Vehicle Passenger 1 Information
Name
Date of Birth-Age
Address
City-State-Zip
Was this person injured?
Yes
No
If Yes, where was this Passenger taken for medical care?
 
Other Vehicle Passenger 2 Information
Name
Date of Birth-Age
Address
City-State-Zip
Was this person injured?
Yes
No
If Yes, where was this Passenger taken for medical care?
 
Other Vehicle Passenger 3 Information
Name
Date of Birth-Age
Address
City-State-Zip
Was this person injured?
Yes
No
If Yes, where was this Passenger taken for medical care?
 
Witness 1
Name
Address
City-State-Zip
Telephone Number
 
Witness 2
Name
Address
City-State-Zip
Telephone Number
 
Use this area for additional information:

Send any other additional information you may have for this report within the 24 hour time frame to:

Risk Management
400 East Second Street
Charlotte, NC 28202-2856

704-336-330 Phone
704-336-7548 Fax
704-336-5943 TTY for hearing impaired

 
City of Charlotte