HomeMy WebLinkAbout106.014 - FC-05, Automobile Accident or Loss
ADMINISTRATIVE MANUAL
FORMS
106.014 AUTOMOBILE ACCIDENT OR LOSS (FC-05)
EFFECTIVE: SEPTEMBER 2008
Current Revision Date: 03/11/21 Next Revision Date: 03/11/26
Author’s Name/Rank: Robert Van Tassel, Battalion Chief Review Level: 5
Administrative Support:
Evelyn Yin-Zepeda,
Management Analyst II
Section 106.014
Page 1 of 6
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 FC-
05 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.
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
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4. Business and Fiscal Services Division:
a. Distribute copies of reports to responsible individuals and
departments, including Fleet Management as appropriate.
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
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Staff/City Intranet Portal/City Forms Management/Personnel Service-Risk
Management
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
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AUTOMOBILE ACCIDENT OR LOSS NOTICE
Forward to: RISK MANAGEMENT DIVISION
2600 Fresno Street, RM 1070 Fresno, CA 93721 Phone: (559) 621-6900
DEPARTMENT: DEDUCTIBLE INFORMATION
DIVISION: FUND: ORG:
TIME & PLACE DATE & TIME OF LOSS OR ACCIDENT LOCATION
CITY
ATUOMOBILE
YEAR MAKE MODEL ASSET # VIN # LICENSE NO. & STATE
NAME OF DRIVER ADDRESS AGE PHONE
FOR WHAT PURPOSE WAS AUTOMOBILE BEING USED AT TIME OF ACCIDENT?
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? POLICE CASE NUMBER
Yes No
DAMAGE TO
PROPERTY OF
OTHERS*
OWNER ADDRESS PHONE
OTHER DRIVER ADDRESS PHONE
LIST DAMAGE ESTIMATED COST OF REPAIRS
IF AUTOMOBILE, MAKE & YEAR LICENSE NO. & STATE
WAS OTHER CAR INSURED? NAME OF COMPANY & POLICY NO.
Yes No
PERSON
INJURED*
PASSENGER PEDES-
TRIAN EXTENT OF INJURIES NAME ADDRESS AGE INSURED’S
CAR
OTHER
CAR
WITNESSES*
NAME ADDRESS PHONE
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
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AUTOMOBILE ACCIDENT OR LOSS NOTICE
Forward to: RISK MANAGEMENT DIVISION
2600 Fresno Street, RM 1070 Fresno, CA 93721 Phone: (559) 621-6900
WITNESSES
(continued)
NAME ADDRESS PHONE
Complete the following diagram showing direction and positions of automobiles involved. Clearly designate point of contact.
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 ++++++++++++++++++++
DAMAGE TO
PROPERTY OF
OTHERS
(continued)
OWNER ADDRESS PHONE
OTHER DRIVER ADDRESS PHONE
LIST DAMAGE ESTIMATED COST OF REPAIRS
IF AUTOMOBILE, MAKE & YEAR LICENSE NO. & STATE
WAS OTHER CAR INSURED? NAME OF COMPANY & POLICY NO.
Yes No
PERSON
INJURED
(continued)
NAME ADDRESS AGE
PASSENGER PEDES-
TRIAN EXTENT OF INJURIES INSURED’S
CAR
OTHER
CAR
Indicate by arrow N
direction of north
Section 106.014
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