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Services - Automobile Incident Report

Services - Automobile Incident Report

ATBE Automobile Fund Incident Report

Instructions: An authorized representative of an ATBE Covered Party is to use this form to report to ATBE, within 7 days of the Incident, an Incident involving a Member board owned or Covered Party operated Covered Automobile, as defined in the Coverage Agreement. Transmit with this form or immediately upon receipt, if after submission of this form, a copy of the official police accident report. Note that a Claim or Loss should be submitted separate from the Incident Report and pursuant to the Notice of AL Claim Procedure or Notice of APD Loss Procedure.  (NOT for use by potential claimants)

Complete the form below OR
download and print the form and return it and all documents to ATBE:

Board of Education Employee Involved in Incident

1. Does the driver have a valid Alabama driver's license and commercial driver's license, if required for the type of Automobile to be driven? *

If no, why not?

2. Does the driver have appropriate certification from the Alabama State Department of Education, if required, including but not limited to Alabama Department of Education School Bus Driver Certificate and documentation maintained by the Board evidencing the driver's compliance with Ala. Code Section 16-27-4.1 and applicable Alabama Administrative Code provisions (Physicals for School Bus Drivers)? *

If no, why not?

3. Is the driver an Employee of the Board (a person duly elected as a superintendent of the Board, employed by the Board as a superintendent, employed by the Board as a chief school financial officer, or whose employment, pursuant to the Code of Alabama, was recommended in writing by the superintendent and approval, thereof, by the Board recorded in its minutes; and a person who meets the Internal Revenue Service definition of employee)? *

Board of Education Vehicle Involved in Incident

Claimant(s) or Potential Claimant(s)

Provide name, address, and telephone number for each; if claimant is a minor provide the age of the minor and the name of a parent or legal guardian. *

Witness(es)

Provide name, address, and telephone number for each. *

Description of Incident, including statement by board employee driver involved in the Incident

Include a description of the facts surrounding the Incident (separate from any information on police report), a description of any property belonging to the claimant or potential claimant that may have been damaged, and any photographs of any damaged property and Incident location to illustrate location of vehicle(s). *

Separate from the description and statements above, provide a copy of the official police accident report. (Upload Supporting Documentation Below.)

Board of Education Contact Regarding this Incident

Upload Supporting Documentation

Attach File(s). Total upload cannot exceed 250MB.

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Note: Additional supporting documentation and/or photographs may be emailed directly to lhs@hestersellers.com.

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