University of Arkansas Motor Vehicle Accident Report	MISC-110 3-23-04
University Vehicle:
Driver’s Name	Driver’s License #:
Home Phone	Date of Birth	Department
Vehicle Fleet #	Campus Phone #
Vehicle year/make/model	Vehicle ID/VIN #
Accident Location (City or Town)	Street/Road/Hwy
Accident Date	Accident Time	AM	PM
Driver description of Accident (Give clear detailed account of: where you were going; what load you were carrying; speed; amount of traffic; how accident occurred; weather; road conditions; etc.)
Other Vehicle(s):
Driver’s Name	Driver’s License #
Address	Driver’s Phone #
Owner’s Name	Owner’s Phone #
Vehicle year/make/model	License #
Owner’s Insurance Carrier	Agent’s Name
Injury to Person(s):
Name/Address of person(s) injured in University Vehicle	Name/Address of person(s) injured in Other Vehicle
Witnesses:
Name	Address
Investigating Officer’s Name	Police Department
The information contained on this report is true and correct to the best of my knowledge and belief.
Signature of University Vehicle Driver	Date