Accident Report / AF5020-B
07/2017
This form is to be used for any vehicle covered under Rocky View Schools’ vehicular insurance policy. The form is to be completed and submitted to the Service Response Centre as soon as possible after the collision. All collisions must be reported, even if there is no damage to the RVS or Bus Contractor vehicle. For collisions involving an RVS owned vehicle, injuries need to be reported on a WCB form needs in addition to being included on this report. The WCB form must be submitted to your supervisor no later than 24 hours after the incident. Once complete this form can be submitted by email to faxed to: 403.945.4110. Questions can be directed to the Service Response Centre through the main switchboard at 403.945.4000
Report Submitted by: / Phone Number:Email Address: / RVS Department/Bus Contractor:
Date of Incident: / Time of Incident (use 24 hr clock):
Location of Incident:
Type of Incident:
Break In / Collision (Single Vehicle)
Collision (Multi Vehicle) / Fire
Theft / Vandalism
Other (Please specify):
How many vehicles were involved / Was non-vehicular property damaged?:Y / N
Please list property damaged (non-vehicular property):
Have the police been notified?: Y / N / Police Report Number (if applicable):
Road Conditions:
Dry Gravel Icy Wet Other (specify):
Weather Conditions:
Clear Fog Rain Rain Snow Other (specify):
Details of Incident:
RVS or Bus Contractor Vehicle/Driver Information
Vehicle Identification Number: / RVS Owned?: Y / N
Owner (if not RVS owed):
Vehicle Type: / Vehicle Make:
Vehicle Model: / Year:
Serial Number: / Mileage:
Driver First Name: / Driver Last Name:
RVS Job Title: / Employee ID Number:
Drivers License Number: / Year Licensed:
Phone Number: / Operations Base:
Address:
Other Vehicle/ Drivers* Involved (if applicable):
*If more than two vehicles are involved please copy this page and complete each additional vehicle separately.
Vehicle Type: / Vehicle Make:
Vehicle Model: / Year:
Serial Number: / Colour:
Driver First Name: / Driver Last Name:
Phone Number: / Alt. Phone Number:
Drivers License Number:
Insurance Company: / Policy Number:
Witnesses
Witness #1
Witness First Name: / Witness Last Name:
Phone Number: / Alt. Phone Number:
Witness #2
Witness First Name: / Witness Last Name:
Phone Number: / Alt. Phone Number:
Office Use Only
Received by:RVS Position:
Date:
Rocky View Schools - 2651 Chinook Winds Drive SW - Airdrie AB - T4B 0B4; p. 403.945.4000; f. 403.945.4001 Page 1 of 2