Reporting of Automobile Accidents - California

1 STATE OF California STATE OF California - DGS OFFICE OF RISK AND INSURANCE MANAGEMENT. Direction Points of Indicate Reporting OF Automobile Accidents accident IDENTIFICATION. STD. 269 (Rev. 8/2016). REPORT NUMBER. The state administers a vehicle liability self-insurance program against loss for personal injury and property damage to others. The program protects any officer or employee of the state when IMPORTANT. WEATHER CONDITIONS. operating a vehicle on official state business. Complete entries below, detach this card and give to other driver who may need information for financial responsibility form. All vehicle accident reports (STD 270) must be received by the SHOW DIRECTION AND POSITION OF. COUNTY. STATE DRIVER FULL NAME. Office of Risk and Insurance Management (ORIM) within 2 business days after the accident .

2 The report must be completed by the OTHER VEHICLE. ALL VEHICLES IN accident . NAME STREETS OR ROADS - STATE VEHICLE. STATE DRIVER WORK TELEPHONE NUMBER. driver and reviewed and approved by their supervisor. The vehicle OCCUPANTS OF OTHER VEHICLE. OCCUPANTS OF STATE VEHICLE. accident report, along with any additional information related to STATE DRIVER LICENSE NUMBER. the accident should be emailed to ORIM at accident DETAILS. DEPARTMENT EMPLOYED BY. DO NOT DISCUSS accident . road CONDITIONS. DIAGRAM OF accident . WITH ANYONE EXCEPT: DATE OF accident . 1. Investigating Traffic Officers 2. Your Supervisors CITY. INVESTIGATED BY. accident LOCATION. 3. Authorized State Officers NAME AND ADDRESS. 4. Office of Risk and Insurance Management Claims Analysts YEAR / MAKE / MODEL OF STATE VEHICLE.

3 accident LOCATION (Address, Intersection, Etc.). LICENSE NUMBER OF STATE VEHICLE. DATE. COMPLETE ENTRIES ON accident INDENTIFICATION. ANY INQUIRY REGARDING accident MAY BE ADDRESSED TO: CARD DETACH AND GIVE TO OTHER DRIVER. DEPARTMENT OF GENERAL SERVICES. OFFICE OF RISK AND INSURANCE MANAGEMENT. 707 THIRD STREET, FIRST FLOOR SUITE 1-150. WEST SACRAMENTO, CA 95605 (916) 376-5300. Email: 1-800-900-3634 Toll Free TIME. DOB. DOB. PHONE. PHONE. PHONE. PHONE. PHONE. CITY. CITY. ASK NAMES AND ADDRESSES OF WITNESSES FIRST. INJURED PERSONS. OTHER VEHICLES. YEAR / MAKE / MODEL. IMPORTANT. DRIVER'S LICENSE NO. VEHICLE LICENSE NO. REGISTERED OWNER. HOSPITAL TAKEN TO. HOSPITAL TAKEN TO. DRIVER'S NAME. ADDRESS. ADDRESS. ADDRESS. NAME. NAME. NAME.

4 ADDRESS. ADDRESS. ADDRESS. ADDRESS. NAME. NAME. Reporting OF CLAIMS. All vehicle accident reports (STD 270) must be received by ORIM within 2 business days after the accident . The report must be completed by the driver and reviewed and approved by their supervisor. The vehicle accident report, along with any additional information related to the accident should be emailed to ORIM at OFFICE OF RISK AND INSURANCE MANAGEMENT. (916) 376-5300. (800) 900-3634 TOLL FREE.