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HomeMy WebLinkAboutC02-282 Family Visitor Programllvmo� llm�
AGREEMENT BETWEEN
THE COUNTY OF EAGLE, STATE OF COLORADO
AND
FAMILY VISITOR PROGRAM
THIS AGREEMENT made this 1 Oth day of September, 2002, by and between the County
of Eagle, State of Colorado, a body corporate and politic, ("County") and the Family Visitor
Program, hereinafter "Contractor."
1. AGREEMENT:
This Agreement shall commence on September 10, 2002, and shall continue through the time
that the Contractor provides Early Head Start services for the Eagle County Early Head Start
program. Consideration under this agreement is $1.00 and other such good and valuable
consideration the receipt and sufficiency of which is hereby acknowledged by the parties.
2. SCOPE:
The purpose of this agreement is to make available to the Contractor the use of an Eagle County
Early Head Start vehicle to provide program related transportation for families enrolled in the
Eagle County Head Start program. The vehicle may be used by the Contractor's Early Head
Start staff in the conduct of home visits, group socialization activities, parent involvement
projects, and Early Head Start staff and parent training. The vehicle may only be driven by Early
Head Start employees of the County or employees of the Contractor. There shall be no personal
use of the vehicle
The vehicle made available to the Contractor is a 2000 Ford Windstar mini -van, Eagle County
vehicle # 8027, Colorado license 024-AVL, VIN ## 2FMZA5041YBC67240.
3. TERMINATION: The County may terminate this Agreement upon ten (10) days written
notice to Contractor if it is deemed by the County in its sole discretion, that the Contractor is not
fulfilling the program as specified in this Agreement, or for any other reason. Upon such
termination the vehicle shall be returned to the County.
Not withstanding the foregoing, in the event of misuse of the vehicle or default of the terms set
forth herein, the vehicle shall be immediately returned to the County.
4. CONTRACTOR'S DUTIES: The Contractor shall comply with the following requirements:
A. The Contractor will restrict the use of the vehicle to Early Head Start authorized activities
noted in Section 2. Of this agreement, and shall abide by Eagle County Motor Pool Policy,
(Attachment A)
B. The Contractor shall maintain adequate records of mileage and program activities for
reporting to the County. The Contractor shall maintain all records pertaining to this Agreement
for a minimum of three years and may be subjected to an audit by federal, state or county
auditors or their designees, as requested. If misuse of the vehicle and funds is discovered by an
auditor, the Contractor shall return said vehicle to the County.
Agreement between Eagle County and Page 2
the Family Visitor Program
C. The Contractor hereby authorizes the County to perform audits or to make inspections during
normal business hours, for the purpose of evaluating performance under this Agreement.
D. The Contractor shall comply with all applicable rules and laws governing motor vehicle
operation in Colorado and any and all drivers shall possess a valid Colorado Driver's License.
Further , all drivers must meet the minimum requirements relating to driving records as set forth
in the Eagle County Motor Pool policy (see Attachment A). The Contractor shall be solely
responsible for ensuring proper licensing and training of those staff persons operating the vehicle
provided under this Agreement.
E. The Contractor shall provide the County with monthly reports concerning mileage by
program activity under this Agreement.
F. The Contractor shall transport the vehicle to the County Motor Pool Division in Gypsum,
Colorado for regularly scheduled vehicle maintenance and for the repair of any vehicle damage
and operation problems. The Contractor shall immediately notify the County Motor Pool
Division of any vehicle damage or problems in the operation of the vehicle. The Contractor
shall immediately notify the County Motor Pool Division of any accidents or motor vehicle
violations involving the operation of the vehicle. The Contractor will be financially liable for
any routine maintenance or vehicle repair that is not completed by or specifically authorized by
the County Motor Pool Division.
5. COUNTY DUTIES:
A. Eagle County will provide the following for the operation of this vehicle:
Vehicle Maintenance and Repair Through the County's Motor
Pool division
Gasoline Through the County's Motor
Pool division in El Jebel.
6. NOTICE:
Any notice required under this Agreement shall be given in writing by registered or certified
mail, return receipt requested which shall be addressed as follows:
THE COUNTY: THE CONTRACTOR:
Eagle County Health & Human Services Family Visitor Program
Post Office Box 660 P.O. Box 1845
Eagle, CO 81631 Glenwood Springs, CO 81602
Notice shall be deemed given three (3) days after the date of deposit in a regular depository
of the United States Postal Service.
Agreement between Eagle County and Page 3
the Family Visitor Program
7. ASSIGNMENT:
The Contractor shall not assign any of its rights or duties under this Agreement to a third party
without the prior written consent of County. Any assignment without the prior written consent of
County shall cause this Agreement to terminate.
S. MODIFICATION:
Any revision, amendment or modification to this Agreement, shall only be valid if in writing and
signed by all parties.
9. INSURANCE :
At all times during the term of this Agreement, Contractor shall maintain in full force and effect
the following insurance:
Type of Insurance Coveraize Limits
Comprehensive Automobile Liability including $150,000 per person and
all owned, non -owned and hired Colorado vehicles $600,000 per occurrence as
(Eagle County must have proof of insurance with specified in the Governmental
Eagle County Government named as an additional Immunity Act, whichever is
Insured party and proof that all drivers of the vehicle greater.
will be covered by said insurance prior to making
said vehicle available to the Contractor.)
Workers' Compensation
Employers Liability, including occupational
Disease
Comprehensive General Liability, including
Broad form property damage
Statutory
$500,000
$150,000 per person and
$600,000 per occurrence or as
specified in the Colorado
Governmental Immunity Act,
whichever is greater
Contractor shall purchase and maintain such insurance as required above and shall provide
certificates of insurance in a form acceptable to Eagle County upon execution of the Agreement.
10. MISCELLANEOUS:
A. The parties to this Agreement intend that the relationship of the Contractor to the County is
that of independent contractor. No agent, employee or volunteer of the Contractor shall be
deemed to be an agent, employee or volunteer of the County.
B. This Agreement shall be binding upon and inure to the benefit of the Contractor and the
County and their respective heirs, legal representatives, executors, administrators, successors and
assigns. Neither party may assign or delegate any of its rights or obligations hereunder without
first obtaining the written consent of the other party.
Agreement between Eagle County and Page 4
the Family Visitor Program
C. In the event of litigation in connection with this Agreement, the prevailing party shall be
entitled to recover its attorney fees and costs, staff time and any other claim related expense.
D. The invalidity or unenforceability of any provision of this Agreement shall not affect the
other provisions hereof, and this Agreement shall be construed as if such invalid or
unenforceable provision was omitted.
E. Contractor shall indemnify and hold harmless the County, its Board of Commissioners, and
the individual members thereof, its agencies, departments, officers, agents, employees, servants
and its successors from any and all demands, losses, liabilities, claims or judgments, together
with all costs and expenses, including but not limited to attorney fees, incident thereto which
may accrue against, be charged to or be recoverable from the County, its Board of
Commissioners, and the individual members thereof, its agencies, departments, officers, agents,
employees, servants and its successors, as a result of the acts or omissions of Contractor, its
employees or agents, in or in part pursuant to this Agreement regarding use of an Eagle County
vehicle or arising directly or indirectly out of Contractor's exercise of its privileges or
performance of its obligations under this Agreement.
F. The Contractor shall comply with all applicable laws, resolutions, and codes.
G. Notwithstanding anything to the contrary contained in this Agreement, the County shall have
no obligations under this Agreement, nor shall any payments be made to Contractor in respect of
any period after July 31 st of each calendar year during the term of this Agreement, without the
appropriation therefor by the County in accordance with a budget adopted by the Board of
County Commissioners in compliance with the provisions of Article 25, Title 30 of the Colorado
Revised Statutes, the Local Government Budget Law (C.R.S. §29-1-101 et.seq.) and the TABOR
Amendment (Colorado Constitution, Article X, Sec. 20).
H. This Agreement shall be governed by the laws of the State of Colorado. Jurisdiction and
venue for any suit, right or cause of action arising under, or in connection with this Agreement
shall be exclusive in Eagle County, Colorado.
I. This Agreement supersedes all previous communications, negotiations and/or agreements
between the respective parties hereto, either verbal or written, and the same not expressly
contained herein are hereby withdrawn and annulled. This is an integrated agreement and there
are no representations about any of the subject matter hereof except as expressly set forth in this
Agreement.
J. Contractor hereby certifies that it has read the Agreement, understands each and every term
and the requirements set forth herein, and agrees to comply with the same.
Agreement between Eagle County and Page 5
the Family Visitor Program
IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date first
set forth above. The parties hereto have signed this Agreement in triplicate. Two counterparts
have been delivered to County and one to the Contractor.
COUNTY OF EAGLE, STATE OF COLORADO
By and through its Board of County Commissioners
L.
ATTE T: wv�)
Clerk to the Board of County Commi
CONTRACTOR: Family Visitor Program
.,
Road & Bridge
(970) 328-3540
fax: (970)328-3546
TDD: (970) 328-8797
Eagle District
Northwest District
Southwest District
Motor Pool
Landfill
EAGLE COUNTY, COLORADO
'Afk,uA A
P.O. Box 150
Eagle, Colorado 81631-D250
3289 Cooley Mesa Roan
Gypsum. Colorado 8163 1
EAGLE COUNTY
MOTOR POOL
POLICY
revised February 14, 2001
Motor Poo! Policy
All persons who use Count Vehicles
Procedures. EmployeesY hicles are bound by the terms of thesePolicies -
who violate these policies are subject to disciplinary and
up to and including termination. Employees must ! c�plinary actions, -
accordance with all local, state and federal laws. operate County Vehicles in
All County employees are to be aware that the County insurance and governmental
scope of duties. Y vehicles are used with permission, within the
These policies and procedures may apply to County employees using their own
vehicles for County business unless otherwise stated.
These policies and procedures attempt to anticipate
pate as many as possible of the various
situations which require rules and regulations. ons. Other situations will arise which have not
been previously experienced or could not have b
addressed herein. Contact the Fleet Supervisor any
anticipated, and are therefore Rot
y time you have a question.
E
4. 1�i� `qW
VEHICLE ASSIGNMENT AND USE
A. GENERAL USE OF COUNTY VEHICLES
1. The operation of a County vehicle is a privilege which may be withdrawn at
any time by the Board of County Commissioners. Use of County vehicles is limited to
County employees, who by the nature of their duties, have a need to use County
vehicles to accomplish their job, as determined by their Elected Official or Department
Director.
2. Eagle County classifies its positions with regard to the need to use a County
vehicle for County business, as: Non -driving (never driving on County business);
Marginal (occasional use, driving not essential to job functions); and Essential (vehicle
use required to perform job functions).
Annual Motor Vehicle Record (MVR) checks are run on all county employees in
positions classified as Essential driving positions to assure that they have an
acceptable driving record.
If an employee's MVR shows an unacceptable driving record, the situation will be
reviewed by the employee's Department Director or Elected Official; they will determine
what action will be taken, up to and including termination. If a Department Director's
MVR shows an unacceptable driving record, the situation will be reviewed by the
County Manager/Attorney. if the County Manager or County Attorney's MVR shows an
unacceptable driving record, the situation will be reviewed by the Board of County
Commissioners.
An employee in a position where driving is an essential function of that job who has
their driver's license suspended or revoked are subject to disciplinary action, up to and
including suspension or termination.'
3
`✓ `
Any employee convicted of an alcohol or drug related offense which occurred while
driving a County vehicle, or while in any vehicle on County business, will be subject to
disciplinary action, up to and including termination.
An employee or an applicant for employment in positions where driving is essential will
be subject to drug test administered after an offer of employment is made but before
employment begins, and random drug testing while employed. (See Drug -Testing
Policy) Employees subject to federally mandated drug testing will be tested in
accordance with those requirements.
Eagle County will run a Motor Vehicle Record (MVR) check on applicants for
employment for positions that require driving as an essential function of the job. If the
applicant's driving record is unacceptable (see above), they will no longer be
considered for employment in that position. For applicants, the three years referred to
above -date back to three years prior to their making application for this position.
3. In addition 'to #2 above, all County employees who operate County vehicles
shall:
A. Maintain a valid Colorado driver's license appropriate to the kind of
vehicle being operated, an comply with all associated rules, regulations and standards
associated with the privilege of operating a motor vehicle in Colorado.
,
B. Be responsible for reporting all accidents and violations of these
policies and procedures.
C. Safeguard the vehicle and its passengers from accidents, damage,
and abuse to the reasonable extent of their ability to do so.
D. Wear seat -belts at all times when operating a vehicle and insure that
all passengers do so as well. f
E. Perform limited maintenance (i.e., observing damage, keeping the
vehicle interior clean, etc.).
F. Keep the Fleet Supervisor informed on a regular basis of the condition
of vehicles and cooperate to ensure that the vehicles are delivered for preventive
maintenance and inspection whenever repairs are scheduled or required.
0
B. COUNTY -VEHICLES POLICY
1. Operating a vehicle while using or while under the influence
alcohol which are illegal or which impair the operator's ability of drugs or
Please refer to Drug Free Workplace polio in the Employee is strictly prohibited.
Y. mployee Handbook.
2. County vehicles shall be used for County business onl
for personal use without the express written permission o Y and cannot be used
Commissioners, employee's Department Director f the Board of County
or Elected Official.
3. Persons not employed by the County are not permitted to d ' County vehicle, unless on official County business or as a rive or ride in a
Manager or the BOCC. approved by the County
4. Pets are not to be carried in or on any County vehicle exce t f of Animal Control, the Sheriffs canine unit, or with the written e P or the purpose
permission of the BOCC.
5. Smoking is not permitted in County vehicles.
6. A vehicle in the General Motor Pool must be refueled before bet
the Motor Pool if the fuel tank is not more than three-quarters full. s returned to
refueled at one of the County fuel tanks, at the Eagle Yard or Vehicles must be
refueling is necessary on an Out trip or in the eventGypsum Yard, unless
of County refueling facilities is located in the check-out booof a emergency. A map
Refueling hours for the Eagle Yard in the winter are k for each vehicle.
8:00 a.m. - 5:00 p.m.; summer
hours are 7:00 a.m. - 5:30 p.m. Refueling hours for the Gypsum Ya d
day, 7 days a week. If the vehicle cannot be refueled duringabove hour
the r are r hours a
refuel the next morning prior to returning book and keys to he s, please
Information Booth.
The following are instructions for operating the County's fuel
pumps:
1. Enter your employee number
2. Enter the vehicle number
3. Enter odometer (mileage) reading from vehicle.
4. Enter department number
5. Enter pump number
'# Note: This means you will need all these numbers hand when n you fuel a vehicle.
5
7. If an employee or a department has a Count
long-term use, it is the employee or department's y Vehicle assigned to them for .
fueled and to notify the Fleet Office of an damage,
to keep the vehicle
problems. y 9e, breakdown, or mechanical
C. MOTOR POOL VEHICLE CHECK-OUT AND RETURN PROCEDURE
I. Vehicles will be checked out -by calling the Motor Poo
The keys will be picked up at the Information Booth in theI Office at ext. 3540.
building after 8:00 a.m. and should be returned prior County Administration
otherwise approved by the appropriate Department Ditecctortor p.m. each work day unless
r.
2. After use, all vehicles from the general motor pool must be ret
designated motor pool. parking lot, pulled into the assigned s urned to the
assigned) locked and the keys and book returned tot a Info pace. cif one has been
oration Booth.
D. PREVENTIVE MAINTENANCE PROCEDURES FOR COU
NTY VEHICLES
1. Damage, breakdowns or mechanical Problems
Supervisor as soon as Possible. P ors shall be reported to the Fleet
P Instructions for after-hours vehicle problems can be
found in the vehicle's check -out book. The last person to have
checked out a vehicle
may be held responsible for all unreported problems or lama .
ge not previously reported.
2. The interior of the vehicle should be kept clean of all times.
responsibility to remove any trash from the vehicle before returning
It �'
s the driver's
ruing it to the parking lot.
1P
0
lq�
SAFETY
A. VEHICLE SAFETY
1. Loss and accident prevention is the responsibilityof all Count
The BOCC expects the aggressive support'of all Count employees Y employees.
the goal of reduced losses. The personal safe o f y Pl°Pees in accomplishing
importance. The County seeks to rouid all employees is of primary
p e the safest possible working conditions,
proper safety equipment, job instruction* and proper supervision of safe w
performance. To that end, the 100tor Pool seeks to provide Countywork
vehicles in good working condition *so that they may car out • employees with
efficient manner. County employees are directed to c ry their duties in a safe and
and procedures in the course of operations of Countycomply with all safety regulations
custody of any user should knowingly be returned vehicles. No vehicle in the
unsafe practices or condition observed b County t° service in an unsafe condition. Any
reported to the Fleet Supervisor. Y employees will be immediately
2. County employees involved in an accident in a County vehlcle ma be
required to attend a Defensive Driving training course. Y
B. TRAFFIC VIOLATIONS
i . If the ability to drive is essential to your job, all traffic violations potentially
resulting in suspension and/or revocation of your driver's license or an char es
involving drugs or alcohol must be reported in writing to the appropriate ele g
or department director immediately. elected official
2. All other citations received for violations occurring while operating a County vehicle must be reported to the appropriate elected official or department P g
five days of the date of the conviction thereon. director within
3. The driver of a vehicle is responsible for all fines and related --costs and
expenses for parking an/or traffic tickets received while operating the vehicle exce t
tickets resulting from faulty equipment which is the responsibility of the Co P for
County .
VA-
y
DEPARTMENT. OR OFFICE POLICIES
Because of the specialized needs or duties -of individual offices t
specialized policy for assigned vehicles. As to vehicles they may need a
departments those departments may adopt.
their assigned to individual
policy which shall govern the operation p own departmental or office motor pool
of those assigned vehicles. A copy of the policy
shall be provided to the Board of County Commissioners and the
case of any conflict between the'Office or Departmental Fleet Supervisor. In
Motor Pool Policy shall govern. All Department t or Office
Use Policy the General
p specific policy shall, prior to
the adoption, be provided to the County Attorney and the Human Resources
for review and comment. All Departmental Policies shall at a minimum incluDirector
provisions of section A of the General Use of County Vehicles Section de the
B, expect
paragraph 6, and Section D paragraphs 7 and 2. The entire section *
p al
be
included in the departmental policy. Department may adopt additional
safety shall d
more restrictive provisions as required. provisions and
G
F
EMERGENCY MOTOR' POOL
CALL LIST
Bill Smith - Fleet Supervisor
Home Number: 524-9709
Cell Phone Number: 471-4150
Eddie Velasquez - Light Motor Pool Mechanic
Home Number. 524-5089
Pager Number. 949-2057
FLEET MAINTENANCE OFFICE _ 328-3540
NOTE: If all of the above fails, someone can be contacted b
Dispatch at 479-22a1. Y. radio through Vail
EAGLE COUNTY MOTOR POOL LIGHT VEHICLE PRO
CEDURES
1. Anyone of or combination of the below occurrences
Review Board; one accident involvin vehrmay be reviewed by the
damage or personal injury. or g vehicle damage of $500 or more, property
1 rY mishandling of vehicle, abusive driving, or
failure to follow the motor pool policy.
2- The Review Board will be made 'up of the following:
Commissioners, Motor Pool Fleet Sus County Manager, County
the Employee Supervisor. P erector of Road and Bridge, and
3. All parking tickets are the responsibility of the individual
at the time the violation ticket was issued. assigned to the vehicle
4. County vehicles can NOT be used for any personal use.
5. All Motor Pool vehicles must be returned to the Administration '
lot, backed into the assigned parking space (if one. is assigned)
parking
returned to the Information Booth at the end of -each day,ones) and keys
approved by the County Manager, Board of Commissioners as otherwise
Supervisor. , or Motor Pool Fleet
6. No Motor Pool vehicle is to be used for overnight trips or weekend trips
approved by the County Manager or Board of Commissioners. unless
7. The fuel gauge must read FULL when returned to Motor Pool.
8. Report all vehicle damage or apparent mechanical problems to the
assigns vehicles (328-3540) After hours call WilliaSmith Person who
Supervisor, at 524-9709, or cell phone number 471-41 Motor Pool
524-5089, pager number 949-2057. THE LAST p 50 or Eddie Velasquez at
VEHICLE IS RESPONSIBLE FOR ALL UN ERSREPORTED ON TO DRIVE A
PROBLEMS OR
DAMAGE NOT PREVIOUSLY NOTED.
9. Clean out all trash prior to returning the vehicle to the Motor Pool.
10. While on county business, no drinking of alcoholic or u beverage
drugs prior to or while driving a*county vehicle. This will use of illegal
be dealt with in accordance with the Disciplinary not be tolerated and will
Policy. P ry Action section of the Personnel
11. Motor.Pool policy violations will be reported to the employee and his
supervisor in writing. his/her
Motor Pool Procedure
Page 2
12. Persons not employed.by Eagle County
County vehicle, unless on official are � Permitted to drive or ride in a
cial Eagle County business or as approved by the
County Manager, Board of Commissioners, or the Motor Pool Flee
t Supervisor.
13. No pets are to be carried in or on any vehicle owned b Eagle
. Government. Animal Control vehicles and the y County
EXCEPTIONS. Sheriffs Canine Unit exempt - NO
14. NO SMOKING IN COUNTY •VEHICLES Re
dated May 11, 1992. ference Ordinance Number 92-01,
Revised February 14, 2001
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DIRECTIONS FOR FUEL SYSTEM
GYPSUM YARD
1. Employee Number (enter)
2. Department Number (enter)
3. Vehicle Number (enter)
4. Odometer Reading (entef)
(If odometer reading is not "reasonable", the system
There is a phone located on the side of the wash
will not allow fueling.
the phone up and it will automatically call bay building. Just pick
odometer corrected) y us and we can then have the
5. Pump Number (enter)
Pump 1 - Car wash
Pump 2 and 3 - Diesel
Pump 4 and 5 - Unleaded
Use Pump Should Display
6. Turn pump on and fuel as. usual
If you encounter any problems, please go to the Road
. d and Bridge office.
Fueling Hours
Sunday - Saturday
24 Hours a day
You must fuel the vehicle at either the Eagleou yard
should you alternate between the two and y d or Gypsum yard. At any time
Road land Bridge -office before yards the mileage mush be called in to the
y can fuel the vehicle at the next fueling.
m
DIRECTIONS FOR FUEL SYSTEM
EAGLE YARD
The system will ask you for the following information:
1. Employee Number (enter)
2. Department Number (enter)
3. Vehicle Number( enter)
4. Odometer Reading (enter)
(if odometer reading is not "reasonable", the system will not allow fueling.
You must go to the Road and Bridge Office in d G 9
Have the odometer corrected . g Gypsum or call 328-3540 to
5. Pump Number (enter)
Pumps 1 and 2 - Unleaded
Pumps 3 and 4 - Diesel
Use pump should display
6. Turn pump on and fuel as usual
If you encounter any problems you will have to go to the Road and Bridge office in
Gypsum or call them at 328-3540.
f.
Fueling Hours
Monday - Friday
Summer Hours: 7:00 a.m. - 5:30 p.m.
Winter Hours: 8:00 a.m. - 5:00 p.m.
s
b
• A
WHAT TO Do IN CASE OF AN ACCIDENT
� . If you are qualified and able to do so, render aid � -
fire extinguishers are located in the trunk o to the inured; first aid kits and
f the vehicle.
2. Do not leave the scene or move the vehicle until-t
involved has completed their investigation he laws enforcement agency
vehicles create a definite hazard thecan.� or until they ask you to move it. (!f
location). Y be moved AFTER marking their
3. Notify State Patrol or local policy authority.
4. Call and report accident day or night to Fleet Supervisor
emergency call,list), so arrangements can- be made to take care of the vehicle.
5. Do not admit or den I abili to gD one. Do not discuss the
anyone, other than the police authorities or authorized re accident with
County Government. presentative of Eagle
6. Get the required information from the other driver, driver's license
insurance carrier, etc., and give the other driver the required nfonumber,
q information.
7. Cooperate and comply with the instructions of an law enforcement,
medical personnel. Y ement, fire or
8. Get the investigating officer's name, department, badge or identification icatron number.
9. An accident report must be filed with the Motor Pool division on all accidents
r
involving County owned vehicles within twenty-four hour
the following information: exact location hour,s• You will need to have
weather conditions, names and address date of accident, road and
es of all witnesses and passengers, and
the extent of any vehicle damage.
10. A law enforcement official or the county may you to require y
alcohol test following an accident or traffic violation. have a drug or
be used to determine what, if any, disciplinary Results of such a test could
P ry action is warranted.
,i-Scene Report Of Vehicle in6q�ent
9p
Date and time of incident AM/PM
Location
Road Type Weather Conditions
County Vehicle information
Name of Driver Driver License #
Home Address Phone #
Equipment # Make Model Year
Describe Vehicle Damage
Other Vehicle/Object information
Name of Driver Driver License #
Home Address Phone #
Vehicle Make Model Year Plate # State
Describe Vehicle Damage
Name of Owner
Address of Owner
Deso i be Damage_
Nance of -Insurer Policy #
Injured Parties
Name
Address
Name
Address
Witnesses
Name
Address
Name
Address
Phone#
Investigating Enforcement Agency
State County City
Officer Badge or I #
Photographs taken Yes No If "yes" by whoa,
Draw rough diagram showing position of vehicles in relation to each other and to the
highway. Identify each vehicle by numbered arrow. Indicate North.
Show approximate speed No I._________ ---------- _No 2.
Remarks:
Signatures
Employee
Supervisor
Submit to Supervisor within 24 hours
Date
Date
DISTR_ I=N
I. Contrac B
Co ies to:
I. Accounting