Fresno Fire Department Automobile Accident or Loss Form PDF

ADMINISTRATIVE MANUAL FORMS 106.014 AUTOMOBILE ACCIDENT OR LOSS (FC-05) EFFECTIVE: SEPTEMBER 2008 Current Revision Date: 03/11/21 Author’s Name/Rank: Robert Van Tassel, Battalion Chief Evelyn Yin-Zepeda, Management Analyst II Administrative Support: Next Revision Date: Review Level: 03/11/26 5 PURPO...

ADMINISTRATIVE MANUAL FORMS 106.014 AUTOMOBILE ACCIDENT OR LOSS (FC-05) EFFECTIVE: SEPTEMBER 2008 Current Revision Date: 03/11/21 Author’s Name/Rank: Robert Van Tassel, Battalion Chief Evelyn Yin-Zepeda, Management Analyst II Administrative Support: Next Revision Date: Review Level: 03/11/26 5 PURPOSE The FC-05 form records pertinent information relating to the Fresno Fire Department (FFD or Department) vehicle accidents. APPLICATION This form is used for accidents involving city vehicles. OPERATIONAL POLICY The "Automobile Accident or Loss Notice" will be completed following the process described below and submitted immediately. In all cases, a separate, personally written memo detailing the particulars of the incident is required of each involved member. Written memos together with the FC-05, police report and photographs are submitted through channels to the appropriate deputy chief or division manager. The reports are then forwarded to the Business and Fiscal Services Division. OPERATIONAL GUIDELINE A Police Report and Police Department photographs are to be included with the FC05 for the following: Anytime a Department vehicle is involved in an accident. Injury to a member or citizen has occurred. Damage to Department facilities when caused by any vehicle. Damage to private property when caused by Department vehicle. Section 106.014 Page 1 of 6 Include information in the narrative section indicating if the accident involved travel to or from an incident and the incident number if applicable. PROCESS Complete all sections of the FC-05 including the accident diagram, sign the document, and include the following information: 1. Police Report. 2. Photographs from the Police Department Investigations Bureau. 3. Memos from each crew member involved. Responsibilities: All contacts with Risk Management are made through the Business and Fiscal Services Division. 1. Commanding Officer: a. Ensure prompt and accurate completion of required reports. b. Promptly forward reports, through channels, to Business Services Division. 2. Battalion Chief: a. Review report and forward to Business and Fiscal Services. b. Conduct a timely investigation of incident. 3. Deputy Chief or Division Manager: a. Review report and forward to Business and Fiscal Services. b. Conduct a timely investigation of incident. Section 106.014 Page 2 of 6 4. Business and Fiscal Services Division: a. Distribute copies of reports to responsible individuals departments, including Fleet Management as appropriate. and 5. Department Finance Section: a. Check account information and retain a copy. b. Requisition Risk Management for repair work or replacement of equipment, and issue to responsible division or department. c. Obtain purchase order from Risk Management, and issue to responsible division or Department. d. Coordinate appraisal and repairs of damaged emergency response apparatus with Risk Management, the fire equipment supervisor, and Fire Administrative Services Division. e. Forward a complete copy of pertinent information regarding damage to the other department vehicles to Fleet Management. 6. Fleet Management/Equipment Supervisor: a. Arrange for timely damage appraisal, as directed. b. Forward appraisals to Business Services Division. c. Arrange for repairs to the apparatus with assigned repair facility. d. When repairs are satisfactorily completed, submit written notification to the Business and Fiscal Services Division. e. Retain a complete copy of all reports in appropriate apparatus file. INFORMATION Employees must be logged into the City Intranet to access the Automobile Accident or Loss Form located at: http://sharepoint.fresno.gov/City%20Forms%20Library/Automobile%20Accident%20 or%20Loss.doc Section 106.014 Page 3 of 6 Staff/City Intranet Management Portal/City Forms Management/Personnel Service-Risk DEFINITIONS This section intentionally left blank. CROSS REFERENCES Administrative Order 2-4, Vehicle Accident/Incident and Property Loss/Damage Reporting and Investigating Procedures Section 106.014 Page 4 of 6 AUTOMOBILE ACCIDENT OR LOSS NOTICE Forward to: RISK MANAGEMENT DIVISION 2600 Fresno Street, RM 1070 Fresno, CA 93721 Phone: (559) 621-6900 DEPARTMENT: DIVISION: TIME & PLACE DEDUCTIBLE INFORMATION FUND: DATE & TIME OF LOSS OR ACCIDENT LOCATION YEAR MODEL MAKE NAME OF DRIVER ASSET # ORG: VIN # LICENSE NO. & STATE ADDRESS AGE PHONE FOR WHAT PURPOSE WAS AUTOMOBILE BEING USED AT TIME OF ACCIDENT? CITY ATUOMOBILE WHERE MAY AUTO BE SEEN (ADDRESS)? ESTIMATED COST OF REPAIRS IF THEFT, SPECIFY PROPERTY STOLEN: IF COLLISION OR COMPREHENSIVE, SPECIFY DAMAGE HAVE POLICE BEEN NOTIFIED? Yes POLICE CASE NUMBER No OWNER OTHER DRIVER DAMAGE TO PROPERTY OF OTHERS* ADDRESS PHONE ADDRESS PHONE LIST DAMAGE ESTIMATED COST OF REPAIRS IF AUTOMOBILE, MAKE & YEAR LICENSE NO. & STATE WAS OTHER CAR INSURED? Yes NAME NAME OF COMPANY & POLICY NO. No PASSENGER ADDRESS AGE INSURED’S CAR OTHER CAR PEDESTRIAN EXTENT OF INJURIES PERSON INJURED* NAME ADDRESS PHONE WITNESSES* DESCRIPTION OF ACCIDENT* Date: Signature of Employee Signature of Department Head * USE REVERSE SIDE FOR DIAGRAM AND OTHER INFORMATION OF IMPORTANCE IN REPORTING THE ACCIDENT Section 106.014 Page 5 of 6 AUTOMOBILE ACCIDENT OR LOSS NOTICE Forward to: RISK MANAGEMENT DIVISION 2600 Fresno Street, RM 1070 Fresno, CA 93721 Phone: (559) 621-6900 NAME ADDRESS PHONE WITNESSES (continued) Complete the following diagram showing direction and positions of automobiles involved. Clearly designate point of contact. N Indicate by arrow direction of north INSTRUCTIONS: 1. a. Use solid line to show path of vehicle before accident b. Use dotted line to show path of vehicle after accident 2. Number each vehicle and show direction of travel 3. Show motorcycle by o-o 4. Show pedestrian by o 5. Show railroad by ++++++++++++++++++++ OWNER ADDRESS OTHER DRIVER DAMAGE TO PROPERTY OF OTHERS (continued) ADDRESS PHONE LIST DAMAGE ESTIMATED COST OF REPAIRS IF AUTOMOBILE, MAKE & YEAR LICENSE NO. & STATE WAS OTHER CAR INSURED? Yes NAME PERSON INJURED PHONE NAME OF COMPANY & POLICY NO. No ADDRESS AGE PASSENGER INSURED’S CAR OTHER CAR PEDESTRIAN EXTENT OF INJURIES (continued) Section 106.014 Page 6 of 6