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HomeMy WebLinkAbout2009-03-26 - Resolution No. 09-03 II RESOLUTION NO. 09-03 RESOLUTION OF THE BOARD OF DIRECTORS OF THE YORBA LINDA WATER DISTRICT ADOPTING THE DISTRICT RISK MANAGEMENT CLAIMS POLICY WHEREAS, the District desires to establish and insure that all tort liability claims filed against the District are investigated and settled fairly and expeditiously where legal liability is determined; and WHEREAS, the District desires to dispose of claims based on the merits of the claims; and WHEREAS, the District shall pay only those claims for which it is determined that the District has legal liability and the estimated settlement value for all claims arising out of the occurrence does not exceed the District's Retrospective Allocation Point per occurrence as set by the Association of California Water Agencies Joint Powers Insurance Authority (ACWA/JPIA); and WHEREAS, the District shall refer to ACWA/JPIA those claims for which it is determined that the estimated settlement value of all claims arising out of the occurrence exceeds the District's Retrospective Allocation Point per occurrence as set by ACWA/JPIA. NOW, THEREFORE, BE IT RESOLVED that the Board of Directors of the Yorba Linda Water District shall adopt the guidelines set forth in the District Risk Management Claims Policy, Policy No. 7020-09-06. Section 1: The Risk Management Claims Policy adopted herein shall take effect immediately upon adoption of this Resolution. PASSED AND ADOPTED this 26th day of March, 2009 by the following called vote: AYES: Directors Armstrong, Beverage, Collett, Mills and Summerfield NOES: None ABSENT: None ABSTAIN: None 67 ohn W. Summe field, President ATTEST: Kenneth R. Vecchiarelli, Secretary Reviewed as to form by General Counsel: Arthur G. Kidman, Esq. McCormick, Kidman and Behrens 411 Policies and Procedures Policy No.: Effective Date: Prepared By: Applicability: Yorba Linda Water District 7020-09-06 ) March 26, 2009 (1:5 oA/eD 1'/PtJ,fofiA' /JJ1Te Gina Knight, HR Manager District Wide POLICY: RISK MANAGEMENT CLAIMS POLICY 1.0 PURPOSE A. The purpose of this policy is to establish and insure that all tort liability claims filed against the District are investigated and settled fairly and expeditiously where legal liability is determined. 2.0 POLICY Decisions regarding the disposition of a claim shall be based on the merits of that claim. It is the policy of Association of California Water Agencies Joint Powers Insurance Authority (ACWAIJPIA) to pay only those claims for which the District has legal liability. A. SMALL CLAIMS SETTLEMENT OPTION 1. All claims arising out of the occurrence are for "property damage" only; 2. No claim arising out of the occurrence has any apparent potential for related "bodily injury"; 3. Under the JPIA Member Agency's Settlement Authority: the estimated settlement value for all claims arising out of the occurrence does not exceed the Member Agency's Retrospective "Allocation Point (RAP) per occurrence as identified in the District's current liability insurance policy program invoice on the E- MOD/Premium Calculation Worksheet; 4. The claim settlement or denial arising out of the occurrence can be concluded within sixty (60) days; and 1 5. A settlement under this option should be made only when the claim being considered is determined to be based upon liability covered by the JPIA Liability Program. 3.0 PROCEDURES: SMALL CLAIMS SETTLEMENT OPTION A. When the District as an ACWA/JPIA Member Agency becomes aware of, or is presented with, a claim that meets all of the conditions in the above Policy Statement it shall have the option of settling or denying the claim directly. If the District as an ACWA/JPIA Member Agency wishes to exercise this option, it should adhere to the following guidelines. 1. Investigate the claim for evidence of liability on the part of the District; 2. Determine whether the claim is to be handled informally or whether formal claim presentation is required. Under the California Government Code a public agency need not take any action until a claim is presented that meets the Code requirements. In general terms, JPIA recommends that this procedure be followed. The District may waive the formal claim presentation requirement and simply elect to pay based on its own judgment; 3. If no liability on the part of the District is found, the claim should be formally rejected in writing. 4. If the District accepts liability, it should attempt to settle the claim as rapidly as possible; 5. At any time during the process the District may contact the JPIA, for assistance or refer the claim in progress to JPIA to conclude; 6. Any claim that cannot be settled within sixty (60) days should be referred to the JPIA for handling; 7. A Monthly Small Claims Report (Exhibit A) should be submitted promptly to the JPIA as this will insure that the District is reimbursed for the expenses incurred; 8. Within thirty (30) days of the receipt of the District's report, the JPIA will issue a check to the District for reimbursement of the settled claims plus a $100 administrative fee for each claim settled or denied; 2 9. The settlement reimbursement will be charged to the District in the next retrospective premium calculations. 10. It is important to note that JPIA's policy has changed with regard to the experience modification calculations used in developing the District's deposit premium. Only losses that exceed the District's Retrospective Attachment Point or $15,000 (whichever is less) will be used in the calculation. It is therefore usually in the District's interest to report all small claims. 4.0 PROCEDURES: CLAIMS REPORTING AND HANDLING Except for those claims that the District decides to handle under the "Small Claims Settlement Option", all claims filed under the Liability Program shall be handled according to the following procedures: A. As a general rule, it is important that the District not be drawn into arguments with potential claimants. A major part of JPIA's service to the District is to handle the difficult claimants on the District's behalf. By reporting promptly, the District can take advantage of the service. Once the claim has been reported to the JPIA, District staff should refrain from continued contact with claimants. It is JPIA's responsibility to communicate all settlement offers and to advise claimants of the status of the claim. It is also essential that none of the District's staff give out information concerning the occurrence to anyone but the appropriate law-enforcement investigator, JPIA staff, or others assigned by the JPIA to assist in the investigation of the claim. 1. Initial Reporting: a. All incidents involving damage to property not owned by the District, or injury to non-employees of the District, should be reported promptly to the JPIA by fax or telephone to: ACWAIJPIA 5620 Birdcage Street, Suite 200 Citrus Heights, CA 95610-7632 Phone: (800) 231-57 42 FAX: (916) 965-6847 e-mail: claims@acwajpia.com 3 It is important that the District does not wait for a written claim to be filed before reporting to the JPIA. We realize that it is a legal requirement, but unless JPIA has notice of an incident, they are unable to begin an investigation and are often unable to adequately investigate if too much time has passed between the incident date and the report to the JPIA. If the claim is reported to District's General Counsel, duplicates of all materials should be forwarded immediately to the JPIA as well, so that there will be no delay in JPIA's receipt of the information. All non-auto incidents should be reported on the "Non-Auto- Only Incident Report Form". (Exhibit B). This form is for use by JPIA Member Agencies only to report the incidents to the JPIA. The form should never be given to the claimant for completion. If the loss involves a vehicle accident, please use the "Auto-Only Incident Report Form" (Exhibit C) and also have the driver complete the "Driver's Report of Accident". (Exhibit F). Fax the completed forms to the JPIA. The "Claim Form", (Exhibit D), is the proper form to give to someone to present a claim to the District. If you receive a request for a claim form, it is appropriate to gather as much information as possible and complete an incident form to forward to the JPIA. JPIA needs to receive the Claim Form before all the evidence is gone in order to be able to adequately investigate. Sending JPIA the Incident Report immediately can be of considerable benefit to the District. b. Although all liability and property claims will be handled directly with the JPIA, any emergency claims after 4:30 pm or on weekends or holidays, can be reported to: Cunningham Lindsey Adjusters (800) 235-8784 They provide a 24-hour service for all JPIA Member Agencies. If the above service is used, the claim must also be reported to JPIA on the next business day so JPIA may assume the handling and guidance of the claim. 4 c. A State of California Department of Motor Vehicles SR-1 Form (Exhibit E) should be filed with the Department of Motor Vehicles (DMV) for any incident involving a District- owned vehicle. Filing this form is helpful in making uninsured motorists pay claims or face losing their driver's licenses. Although the law requiring the filing of this' form does not apply to public agencies, filing it helps reduce inquiries from the DMV to your employees. 2. Subsequent Reporting: Forward all correspondence involving a reported claim directly to the JPIA. This includes the following: a. Any claim or letter filed with the District or any subsequent correspondence or notes of conversations with potential or actual claimants; b. Any legal documents or related correspondence from attorneys or other representatives of claimants or insurance carriers; c. Any letters, memos, or notes of conversations, or other inquiries from interested parties; d. Any police or other public agencies' reports that are available; and e. Any photographs, newspaper articles, etc., that the District can provide. 3. Initial investigation: While it is the responsibility of the JPIA to thoroughly investigate and determine liability in any given case, the assistance of the District in the initial investigation is often invaluable. If the District has a representative at the scene, the following guidelines may improve the quality of the investigation: 5 a. Preserving evidence in a timely fashion is critical to the outcome of the investigation. The faster the investigator gets to the accident scene, the less chance there is that details will be lost. Preserving evidence at the accident scene generally results in a much more successful and accurate outcome. Observing and recording evidence such as instrument readings, control panel settings, plus other routine observations such as the weather are essential to a good investigation. b. Photographs, video cameras, drawings and notes are among the most valuable methods of recording and preserving evidence. 1) General and specific scenes should be photographed to provide a comprehensive record. It is generally best to take too many photographs, since it is often difficult to determine what each one will show until they are developed and reviewed. Photographs of objects involved in the accident may need some reference point to show the proper scale. A ruler or coin, photographed alongside the object, is often helpful. 2) In addition, accurate and complete notes that explain the photographs, who took them, and when, significantly increases their value and the likelihood that they will be admitted as evidence in a court of law. We suggest mounting them on a form, such as the sample that appears in the Attachments. This also provides a place for notes concerning the individual photograph. c. Diagrams are also useful to assist us in understanding the nature of the occurrence. The more accurately drawn the better, but even a hand drawn diagram can be used to present the facts and preserve the investigators recollection of the incident. There is a diagram on the back side of the "ACWAIJPIA Driver's Report of Accident" form (Exhibit F) that is useful for vehicle accidents. 6 d. Witnesses, if found and interviewed promptly, may be the most important source of information in any investigation. Record their names, addresses, home and work phone numbers if at all possible. 1) Identifying witnesses is a critical part of an investigation. Do not limit yourself to those who remained on the scene. Discussions with those who are present may lead to others. A canvas of nearby businesses or homes may also prove fruitful. 2) If you choose to interview witnesses, they should be interviewed one at a time in as much privacy as possible. The accuracy of people's recall is highest immediately after the incident. Many things interfere with recall, including discussions with other witnesses, newspaper accounts or just poor memories. Where possible, the interviews should be conducted at the accident scene, which will allow the witnesses to point out what they consider significant. Remember that interviews of this type are fact finding. It is a good idea to point out to the witness that you are only concerned with the facts at this point, not in assessing blame. 3) The interview itself should be conducted in as relaxed an atmosphere as possible. It is far more important that the interviewer be a good listener than it is to think of good questions. Your goal is to get a general idea of what each witness will say, what he saw, and what value he will have as a witness. Take notes as unobtrusively as possible. It may be best to wait until the interview is over before writing anything down. Unless you have had formal training in taking written or recorded statements, we do not recommend that you attempt to do so. 7 -~------~ -~ ~------------------- e. Facts are essential. B. LITIGATION 1) Please try to not put a spin or slant on your report. This creates delays, misunderstandings and tends to actually increase costs as it often results in needless litigation to arrive at the truth. 2) All evidence presented to the JPIA is used to make the appropriate decisions for the District. If you have done a comprehensive investigation, a written report outlining all of the evidence obtained may be of considerable value to JPIA and to the District. 3) The "Incident Report" and "Driver's Report of Accident" forms, while useful for simple situations, have obvious limitations in trying to report on a more complex or detailed investigation. No particular format is required. The goal is the complete and objective "what, when, where and who". 1. The JPIA will select and retain appropriate attorneys to defend the District. 2. When litigation begins, it is important all documents are immediately forwarded to JPIA as soon as they are received by the District. All litigation has a very rigid and usually short time frame in which to respond. Holding a summons or complaint can cause problems for the JPIA in defending the District. 5.0 RESPONSIBILITIES A. It is the responsibility of each employee: 1. To carefully follow the procedures outlined in this policy in order to prevent unnecessary exposure of the District to litigation. 2. To cooperate with the Risk Manager to protect the health, safety and life of District employees and the public. 3. To follow the procedures outlined in this policy in order to document any incidents. 8 B. It is the responsibility of each Department Manager to ensure: 1. Their staff is versed in the procedures outlined in this policy and that their staff is aware of the importance of adhering to the procedures. 2. The Human Resources Department is made aware of any accidents or incidents impacting the District as soon as possible after the accident or incident, but no later than 24 hours after, so appropriate documents, forms and statements may be gathered and forwarded to JPIA and legal counsel. C. It is the responsibility of the Human Resources Manager to: 1. Contact the General Manager/Assistant General Manager to make them aware of any accidents or incidents that could cause an impact to the District. 2. Ensure contact is made with JPIA and/or legal counsel to apprise them of the possibility of claims against the District. 3. Ensure all materials: incident reports, notes, forms, photographs, witness statements, etc. are forwarded to JPIA and/or legal counsel. APPROVED: neth R. Vecchiarelli, General Manager D~ :l-2 I 2oO"J' 9 7020-09-06 Exhibit 1 Yorba Linda Water District Risk Management Claims Policy Acknowledgement Form I acknowledge that I have received and read the provisions contained in this Risk Management Claims Policy. I understand that it is my responsibility to consult my supervisor or the Human Resources Department if I have any questions that are not answered in the Policy. I also understand that the provisions in this Policy are guidelines and are not intended to be construed as all encompassing. I further understand that the Yorba Linda Water District reserves the right to add to, eliminate, or otherwise change, at any time, any of the provisions contained in this Policy. I understand that any changes will be communicated to me through my supervisor and that the General Manager has the authority to implement and interpret this Policy, and to make necessary changes. I understand that it is my responsibility to follow the provisions contained in this Policy and any subsequent modifications or amendment and failure to do so may result in disciplinary action or termination of employment or services. EMPLOYEE'S NAME (printed): EMPLOYEE'S SIGNATURE: DATE: ________________ __ Distribution: Original to Personnel File Copy: Employee 10 ACWA Joint Powers Insurance Authority Monthly Small Claims Report District Name: _________________ _ MonthNear: --------Prepared by: --------------- Date/Time of Date Claim Claimant's Name Amount of Claim No. Incident Received (and driver/if auto claim) Brief Description of What Happened Settlement Approvedby: --------------------------------------White -JPIA Office Copy I Canary-District Office Copy Date Release Settled Attached? Revised January 7, 2003 m >< :::1: -m =i l> I Non-Auto Only Incident Report Form (For Member Ar. encv Use Only) .eMBER AGENCY: MAIL TO: ACWA/JPIA 5620 Birdcage Street, Suite 200 Citrus Heights, CA 95610-7632 Phone No.: ( ) Previously Reported Yes -- Date & Time of Accident Reported By: Mo. Day Year Time AM/PM Phone Number: Location of Loss (Including City & State) Authority Contacted & Report No. Description of Loss Property Owner's Name Address I City Home Phone Business Phone I Estimate of Damages Describe Damaged Property Property Owner's Name Address I City Home Phone Business Phone _I Estimate of Damages Describe Damaged Property ,,·;:.::::UD/ L: .r::.:tt!: ~::·: <· ·')/::l;iwn ;::::.~;;;;,·.,:,:·,; ,[*'::,,_ ., : ,_,,. :. , .. ;,.:r :• '.•: ~·L·: :·;:.:. :: . , :·:· :, •. ~.: .. :. , :>' Name & Address I Phone No. Extent of Injury ~·:;!•:•~;j,~fi;~~~:;f~;,,,::;:;;;;. '.,!;,'<c!}l/> ;, b'iEh:::n:;:;';;', >f•W·!'i T;';:.•·:;'i<i<!;1 !';.i,';~ Name & Address lllame & Address TThis reoort oreoared bv: Date: PLEASE KEEP A PHOTO COPY OF THIS FORM FOR YOUR FILES EXHIBIT B No -- I Zip Code I Zip Code :··:. I Age 1;S'·'::~c>:'::;•:_: .. ,·,.;,.:,•; ..• ,:: .. " .::., Phone No. Phone No. Time: CLM-IRF-100102 MEMBER AGENCY: Phone No.: Date & Time of Accident Mo. Day Year Location of Accident (Including City & State} Description of Accident Driver's Name Address Auto Only Incident Report Form For Member Use Onl MAIL TO: ACWNJPIA 5620 Birdcage Street, Suite 200 Citrus Heights, CA 95610-7632 Previously Reported Yes Reported By: Time AM I PM Reported To: Authority Contacted & Report No. Residence Phone No. City, State Date of Birth Drivers License No. Estimate Amount ( scribe Damage Describe Property (If Auto-Year, Make, Model, Plate No.} Insurance Company/Agent & Phone No. Owner's Name Business Phone No. Address City, State Driver's Name & Address (If Other Than Owner) Business Phone No. Describe Damage Name & Address Extent of Injury ': .. :. ·.,.me & Address This report prepared by: Date: PLEASE KEEP A PHOTO COPY OF THIS FORM FOR YOUR FILES EXHIBIT C No Business Phone No. Zip Code Where Can Vehicle Be Seen Insurance Policy No. Home Phone No. Zip Code Home Phone No. Phone No. Time: CLM-IRF-100102 EXHIBIT 0 Claim Form (A claim shall be presented by the claimant or by a person acting on his behalf ) NAME OF DISTRICT: 1 Claimant name, address {mailing address if different), and phone number. Name: Address{es): Phone Number: { ) 2 List name, address, and phone number of any witnesses. Name: Address: Phone Number: ( ) 3 List the date, time, place, and other circumstances of the occurrence or transaction, which gave rise to the claim asserted. Date: Time: Place: Tell What Happened {give complete information): NOTE: Attach any photographs you may have regarding this claim. 4 Give a general description of the indebtedness, obligation, injury, damage, or loss incurred so far as it may be known at the time of presentation of the claim. 5 Give the name or names of the public employee or employees causing the injury, damage, or loss, if known. 6 The amount claimed if it totals less than ten thousand dollars {$10,000) as of the date of presentation of the claim, including the estimated amount of any prospective injury, damage or loss, insofar as it may be known at the time of the presentation of the claim, together with the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($1 0, 000), no dollar amount shall be included in the claim. However, it shall indicate whether the claim would be a limited civil case. Date: Time: Signature: ANSWER ALL QUESTIONS. OMITTING INFORMATION COULD MAKE YOUR CLAIM LEGALLY INSUFFICIENT! White --JPIA Office Copy I Yellow--District Office Copy Pink--Claimant Copy Revised June 20. 2007 REPORT OF TRAFFIC ACCIDENT OCCURRING IN CALIFORNIA READ IMPORTANT INFORMATION ON BACK AS APPROPRIATE, PLEASE TYPE OR PRINT IN BOXES II OF VEHICLES 1 DA~OF~CIDENT r ACCIDENT' LOCATION-CITY/COUNTY (CALIFORNIA ONLY) EXHIBIT E DMVUSE ONLY ON PRIVA.TE PROPERTY Oves 0No DRIVING FOR EMPLOYER . TIME oF ACCIDENT 0 AM D ~opped D . . . . Hour D FM 0 Moving in Traffic Parked 0 Pedestrian 0 Bicyclist D Other (E.G, ROLLAWAYJ I Oves 0No z :. ,0 .:. ·: DRIVER'S NAME (FIRST, MIDDLE, IJ\ST) .;;;; ' I DRIVER LICENSE NUMBER I STATE DATE OF BIRTH ;i~' :~ DRIVER'S STREET ADDRESS i:~f!::::~CI;:;.TYn;-----------------------:ST.;;it;:;:;J~E--,Z:;;;IP:;-;Cv:O:;::;OE;;----~ ITEL;;"E;::;P:;-;H;;:ON-;;:E7,N;";;UM::;B;;:ER;;;S;-----....L..---'1!-_~I!-_ __ . '~> WI< { ) Hm ( ) , ~ . :lcVE=HIC;;:;l;;;E-;;:(Y;;;-EAR....-.:A;;;;ND'-M~AKEu.:;-) -----,~r..VE;;;;HI:n.C:;LE;;;-;;LICEN=s"'e;;-;:P;;-LA;;;;:TE~O;;;R;7V;;;;EHI~C:;L_,.E I;;:;D;:;ENT:;;:I;;;;FI;;;;-CA;;;;::r;;:;ION=Nu~M;;:;BE~R.---..~..___: __ ..;_ __ ,Ir::ST.:;::ti:;;TE:-=--.-::0=.A""~:=s:-::OVE::-:0::::R:-::~=:::-o- :~): VEHICLEO'MIIER-PERSONORCOMPANY DATE OF BIRTH ,Cl::: I I ·,;z: :1-:AD;;:;;::;OR;;;:E:;;;SS;:------------------;;CI;:;;TY:;--------------------,;st"'I>::;;TE:--...L~!.._....!.,ZI""P'='co""o"'e- ;~;·': ::;~::~~hlrnNS""U"'RANC=e::-:co=M~PAN=vNAM=:;:-E~(N;;:;OT:::-A:::G:-::EN:;:T::-:OR::;-.;8:=ROI(=IER""0:-::AT"'"'T;:;;H;;::-E:;::TIM~E;:-:OF=r:-::HE:-:A""CCI=oE~NT::-----------,.--..::,IPO""L"'IC~Y:-oNU~M"'B;;ERo------------- <m::.~ AOIIA/JPIA 5620 Birdcaqe St.t200 Citrus Heiclhts. CA 95610 MOLC 1001 • • coMPANYNAicNuMssR IPOUcveOOiinuous TPOucvHOLCERNAME · · N/A From: To: Liability Coverage Pool DRIVING FOR EMPLOYER 0 Stopped in Traffic 0 Parked 0 Pedestrian 0 Bicyclist 0 Other (E.G., ROLLAWAYJ DYes D No . >~ :";:· DRIVER'S NAME (FIRST, MIDDLE. LAST) I DRIVER LICENSE NUMBER I STATE ,,~:==:=IVER='S::-:S:::TR::;E::ET:-:A::DD::R::E:::::SS;-----------------ST.-:AT-E __ Z_IP_C_O_DE----~-T~-LE-;_H.l.ON_E_N-~-MB-E-RS ___ H_m _ __,(,_,DI'i..,.,T==:/-=-OF::-:B!.,I~==T'""H-- z ·.~~~~~~~--------r.=~~~~~~~~~~~~~~~--~~~--~----~~~~~~~~~--. _iii ; VEHICLE (YEAR AND MAKE) 1 VEHICLE LICENSE PLATE ORVEHlCLE IDENTIFICATION NUMBER 1 STATE o~= or: .'~. . VEHICLE 0\M'JER-PERSON OR COMPANY DATE OF BIRTH ~ :: ~-===----------------::=:----------'---------:=:--.L_.LI__,I~=-·,aJ;;;·: ADDRESS CITY STATE ZIPCODE ·::~:····. ·~ ', 1-:I::-::NS::-:U:::-RAN~CE:-:CO=:M::cPANY:::-::-:-NAM=-:-:-:c=E-::-(N""OT:-:AG:-::::=SV::-:T:-:OR=::B:=:ROKERJ==:-::AT:::T~H:=E:::::TI::-::ME::cOF=T:-::HE:-:A-::CCI=oe""NT=---------l-r=POLI=CY:-:-:-::NU-::-M:::B:::::ER:------------- NAME AND ADDRESS OF INDIVIDUAL INJURED OR OECEASED ·W' .~~: ;~;.i' NAME AND ADDRESS OF INDIVIDUAL INJURED OR DECEASED I POLICY HOLDER NAME D Injured 0 Deceased 0 Injured 0 Deceased 0 Driver 0 Passenger 0 Bicyclist 0 Pedestrian 0 Driver 0 Passenger 0 Bicyclist 0 Pedestrian II :~~~' OTHER PROPERTY DAMAGED (TELEPHONE POLES, FENCE. UVESTOCI<, ETC.) DAMAGESOr~r50 . .f.I-,P:::::RO:::-P:::E:::RTY=O'MII=ER='S""'NAM,.,-:::E-,AN"'o:-:AO-::OR=ess~---------------------------=D=-'r'i-es_.=!....N....:o ___ _ 1 certify under penalty of perjury under the laws of the State of California that the Information entered on this document is true and correct DATE I PRINTED NAME SR 1 (REV. 512005) WWW 0ADDITIONAL INFORMATION ATTACHED A DMVRLE NUMBER NAME OF INSURANCE COMPANY (NOT AGENCY CA BRDKEIWlE) THAT ISSUED THE UABIUTY PCLICY '1\l"'l'a'I'JI. lJPIA COVERING THE ().O£RATIOJol OF YOLJI VEHICLE ~J'U:'l./ POUCV NUMBER POUCV PERIOD COntinuous I IDLClOOl From: To; DRIVER LICENse NuMaeA N 1-:DA~TE::::=:::o:;::F ~~~c=ciD=:EN:::;T~'-r.::IN-=oR~N:-:::iii:::R:-:e<::::ITY=OR~T::::OI"rtti=-:::,CA::-:UF-:::o::R::::NI::-A ==om.~'tl=-...1.!.;=~-------~-----~--11DAIVER CF YOUR VEHICLE) ~ ~~~~r~~~----------------~~~~~~~---------------*~~~~~~~~ R VEHICLE (YEAR AND MAKE) VEHIClE IDENTIFICATION NUMBER VEHICLE LICENS!; PLATE NUMBER STATE A ~~--------------------------~------~~~----------------~------------~----N DRIVER ADDRESS c E OWNER ADDRESS FLU NAME Of PCI.ICY HDI.DER ADDRESS Sf! , A (ReV. &12006) If the policy was not in effect, this form must be completed and returned to the Department within 20 days. The undersigned company advises that with respect to the reported accident, the policy reported on the reverse side: 0 WAS NOT IN EFFECT 0 Was not a liability policy 0 Did not cover the vehicle/driver Policy Number ________________ _ Signature __________________ _ Title-------------------- Date ______________________ _ 0 Number is not a company policy number Polley Period from ______ to ---------- MAIL TO: Deparbnent of Motor Vehicles Financial Responsibility P. 0. Box 942884 Sacramento, CA 94284-0884 SR •A (RI!V. 5120851 WNW IMPORTANT INFORMATION California law requires traffic accidents on a California street/highway or private property to be reported to the Department of Motor Vehicles (DMV) within l 0 days if there was an irijury, death or property damage. Untimely reporting could result in DMV suspending a driver license. Accidents occurring on December 31, 2002, or prior must result in damages to any one person :SO property in excess of$500, and accidents occurring on January 1, 2003, or after must result in damages in excess of$750 to be reported. Accidents involving vehicles not required to be registered such as an off-road vehicle (OHV), implement of husbandry, or snowmobile or occurring on a military base or occurring on the driver's own property involving only the personal property of the driver and there was no injury or death are not reportable. The law requires the driver to file this SR-1 form with DMV regardless of fault. This report must be made in addition to any other report filed with a law enforcement agency, insurance company, or the California Highway Patrol (CHP) as their reports do not satisfy the filing requirement. An insurance agent, attorney, or other designated representative may file the report for the driver. The law requires every driver and every owner of a motor vehicle to be "fmancially responsible" for any injury or damage resulting from operating or owning a motor vehicle. The minimum insurance level for "financial responsibility" is public liability and property damage coverage of $15,000 for injury or death of one person, $30,000 for injury or death of two or more persons and $5,000 property damage per accident. Comprehensive and collision insurance does not meet the legal requirement. §1806 ofthe California Vehicle Code (CVC) requires the DMV·to record accident information regardless of fault when individuals report accidents under the Financial Responsibility Law or iflaw enforcement agencies or CHI> investigate and make a report. WHEN COMPLETING THIS FORM ... Please print within the spaces and boxes on this form. If you need to provide additional information on a separate piece of paper(s) or you include a copy of any law enforcement agency report, please check the box to indicate 'Additional Information Attached'. If you are the passenger reporting the accident, be sure to identify yourself by using the 'other' box and stating 'passenger' in the explanation. Write unk (for unknown) or none in any space or box when you do not have information on the other party involved. Give insurance information that is complete and which correctly and fully identifies the company that issued the policy. Place the correct National Association oflnsurance Commissioners (NAIC) number for your insurance company in the boxes provided. The NAIC number should be located on your insurance ID card or you can contact your insurance agent or company for the information. Identify any person involved in the accident (driver, passenger, bicyclist, pedestrian, etc.) who you saw was injured or complained of bodily injury or know to be deceased. • Record in the OTHER PROPERTY DAMAGED section any damage to telephone poles, fences, street signs, guard posts, trees, livestock, dogs, etc., meeting the filing requirement, including amount This may require that you contact the owner of the property for an estimate of damages. Once you have completed this report, please mail it to: DEPARTMENT OF MOTOR VEHICLES FINANCIAL RESPONSmiLITY MAIL STATlON J237 P.O. BOX 942884 SACRAMENTO, CA 94284-0884 DMV does not accept reports or take actions against non-reporting or uninsured motorists unless this SR-I form is sent to DMV by someone involved in the accident or their designee and the report is received by DMV within one calendar year of the accident date. ADVISORY STATEMENT The accident information on the SR-1 is required under the authority ofDivisions 6 and 7 of the California Vehicle Code. Failure to provide the information will result in suspension ofthe driving privilege. Except as made confidential by law (e.g., medical information) or exempted under the Public Records Act, the information is a public record, is regularly used by law enforcement agencies and insurance companies, and is open to public inspection. §16005 CVC limits the public record for SR-1 reports to accident involvement, but does allow persons with a proper interest (involved drivers, their employers, etc.) to receive specified information. Individuals may inspect or obtain copies of information contained in their records during regular office hours. The Financial Responsibility Section Manager, 2570 24tb Street, Sacramento, CA 95818 (telephone number: 916-657-6677) is responsible for maintaining this information. SR 1 (REV. S/2005) ------------ ACWA/JOINT POWERS INSURANCE AUTHORITY EXHIBIT F 5620 Birdcage Street, Suite 200, Citrus Heights, California 95610-7632 ***(800) 231-5742 ***fax (916) 965-6847 DRIVER'S REPORT OF ACCIDENT Agency Name: Location of Accident: Accident Date: Time: Select One Road Conditions: Weather Conditions: Direction of Travel of Your Vehicle: Speed: Direction of Travel of Other Vehicle: Speed: Police Report Taken? Select One Police Department: Report No. Name of Police Officer: Badge No. YOUR VEHICLE (VEHICLE #1) Year, Make, Model: Vehicle ID Number (VIN): License Plate No. Driver: Driver License No. Address, City, State: Home Phone No. Department: j Job Title: Supervisor: Damage to your Vehicle: OTHER VEHICLE (VEHICLE #2) Driver: Driver License No. Address, City, State: Home Phone No. Year, Make, Model: License Plate No. State: Insurance Company: Policy Number: Insurance Broker Name: Phone No. Damage to Other Vehicle: Owner Name: Phone No. Address, City, State: OTHER VEHICLE (VEHICLE #3) Driver: Driver License No. Address, City, State: Home Phone No. Year, Make, Model: License Plate No. State: Insurance Company: Policy Number: Insurance Broker Name: Phone No. Damage to Other Vehicle: Owner Name: Phone No. Address, City, State: INJURED PERSONS Name: Phone No. Address, City, State: Extent of Injury: Driver I Passenger I Veh. #: Name: Phone No. Address, City, State: Extent of Injury: Driver I Passenger I Veh. #: Name: Phone No. Address, City, State: Extent of Injury: Driver I Passenger I Veh. #: NARRATIVE REPORT: Briefly describe the accident. Add pertinent information not addressed above. Completed by: Date Submitted: DIAGRAM: Show the position of each vehicle at the time of the accident and number them according to the numbers listed above. Indicate the direction of travel using arrows. Indicate traffic signs or signals. Show stationary objects. * \ Indicate North / Indicate North. <J:J Your Vehicle ([] Other Vehicle(s) ~ Pedestrian rii. liJ Traffic signal y Traffic sign JPIA Driver's Report of Accident Form (revised 10/01/06)