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901 Overview

Throughout the Diocese of Charlotte, we have taken pride in our record of safety. Although our history is exemplary, it is always necessary to strive for improvement of safety practices. This Vehicle Safety Policy is a step in this direction. The intention of this program is to standardize the safety methods and procedures used within our schools, parishes, and agencies throughout the diocese. It is up to us, employers and employees, to become familiar with this policy. Please study this policy carefully and thank you in advance for your cooperation.

902 Procedure for the Purchase, Lease, Sale or Donation of a Vehicle or Bus

If a parish/school/agency wishes to purchase, lease, sell, or donate a vehicle or bus, the following procedures must be followed:

Please note that since all Diocesan-owned vehicles are owned by the Bishop ofCharlotte, all purchase agreements MUST be sent to the Chancellor for review andsignature of the Bishop.

902.1 Purchasing a Vehicle

A letter must be written to the Chancellor requesting permission to purchase a vehicle (car, van, bus or trailer). The letter should include the reason for the purchase and the intended financial arrangements. Once permission is granted, you may proceed to finalize the sale with the dealer or individual.

The vehicle must be titled in the name of the “Roman Catholic Diocese of Charlotte” at 1123 South Church Street, Charlotte, North Carolina 28203. The dealer must send all paperwork to the Diocese for the Chancellor or Bishop’s signature. Only the Chancellor or Bishop can sign the purchase or long term lease agreements. Following the sale or lease, all the signed paperwork must be sent to the Diocese where it will be kept in the Chancery files along with the title when received from the North Carolina Department of Motor Vehicles.

When the annual registration renewals are received by the Diocese, a letter and a copy of the renewal application will be sent to each Parish, School, or Agency / ministry that has a vehicle. Inspection of the vehicle (trailers do not require inspections) should be done at that time and the inspection report and any other paperwork should be faxed or e-mailed to the Chancery. When the new registration card and sticker arrive to the Chancery, a copy will be made for the Chancery files and the original mailed to the owner for placement in the glove compartment.

902.2 Leasing or Renting Vehicles for Diocesan Use

If a vehicle is to be leased or rented for diocesan use, It is the policy of the Diocese of Charlotte that the lease or rental agreement be made in the name of the “Bishop of Charlotte”, and that the parish/school/agency agree to purchase the highest level of rental insurance provided by the lease or rental company. Please note that for Short term leases you are encouraged to purchase the insurance through the lease or rental company as opposed to requesting Catholic Mutual coverage.

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902.3 Selling a Vehicle

A letter must be written to the Chancellor requesting permission to sell or dispose of a Diocesan vehicle. If the vehicle is being sold to an individual, the Chancery will need the exact name and address of the buyer and the date it is being sold to them so that the title can be made out directly to them. The title will be filled out by the Chancery office, signed by the Chancellor or Bishop, notarized and returned to the Parish, School, or Agency Department head or ministry.

902.4 Donated Vehicles

If a vehicle is to be donated to a Parish, School, or Agency then the first thing to do is to have the vehicle inspected by a reputable garage. If the vehicle is in safe operating order, and checks out for all safety requirements, then the Parish, School, or Agency must notify the Chancellor of their intention of accepting a donated vehicle, indicating the vehicle has been checked out and is in safe operating order. Once approved, the vehicle must be titled in the name of the “Roman Catholic Diocese of Charlotte” at 1123 South Church Street, Charlotte, North Carolina 28203. The title should be mailed to the Chancery office for signature of the chancellor or the Bishop and be returned with an insurance certificate. The title then may be taken to the local NCDMV office and, upon paying the appropriate fees, will be issued a temporary plate and registration. Please make copies of all paperwork and return all originals to the Chancery so that they may coordinate with Catholic Mutual Group.

903 Vehicles Belonging to Members of the Public

The Diocese recommends that employees and volunteers be instructed to NOT drive motor vehicles that belong to others in connection with events or business. Car washes and valet parking operated by parishes/schools/agencies are some examples of the types of operations where motor vehicles belonging to others may be operated. Car washes should be arranged so that patrons drive their own cars. Valet parking should be avoided unless it is operated by contractors who provide evidence of insurance and the required Additional Insured endorsements. Please contact the Diocesan Properties & Risk Management Office for assistance in such cases.

904 Volunteer and Employee Drivers of Privately-Owned Vehicles

Under North Carolina Motor Vehicle Code, the owner of the vehicle is responsible for insuring the vehicle. Therefore, insurance coverage for privately owned/operated motor vehicles is not provided to employees, parishioners, or volunteers (including coaches or parents of school children) using personally owned vehicles. Since the owner’s auto insurance is primary, the vehicle must be insured for the following minimum limits as required by Catholic Mutual and the Diocese - $100,000 / person, and $300,000 / occurrence. Volunteer drivers should review their personal automobile insurance policies and obtain the minimum insurance limits as indicated above. The insurance policies they purchase are for their protection.

905 Cellular Phones

State statute does not allow texting while driving. To promote safe driving, employees and volunteers are not to use hand-held cell phones when operating a vehicle. Drivers should park whenever they need to use a hand-held cell phone, except in cases of dire emergency.

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906 Drivers Qualifications

Employees and volunteers who drive any vehicle (other than buses) in the course of their employment/volunteer service to transport other volunteers, clients, or youths, must meet the following qualifications:

Have a valid driver’s license appropriate for the vehicle type (refer to the “Vehicle Typesand Licensing Requirements” discussion in this section).

Be at least 21 years of age.

Have a safe driving history as determined by the results of a Motor Vehicle RecordCheck request submitted to the Properties & Risk Manager in the Diocesan Properties& Risk Management Office. A copy of all approved drivers will be held on file at theDiocese, and must also be held on file at the parish/school/agency for a minimum of 3years past the termination of driving privileges.

Complete the “Defensive Driving Curriculum” course online through CMGConnect.organd provide a copy of the Certificate of Completion to your local parish/ school/ agencyadministrator. (Refer to the Online Training Instructions, Form 10.A).

Abide by the Drug and Alcohol Policy set forth in the Diocese of Charlotte PersonnelPolicies Handbook. Refer to the Diocese of Charlotte Personnel Policies Handbook forfurther information regarding what policies and procedures specifically apply to thoseemployees for whom driving is defined as a part of their job duties.

907 Driver Approval Procedures Required

Drivers who wish to drive a diocesan owned vehicle or drive their own vehicle on a regularand routine basis (more than one time per month) on behalf of the Diocese must do thefollowing in order:

1. Complete and submit the Request for Approved Driver Status form (Form 9.A)available in Spanish online, along with a clear color copy of their driver’s licenseand automobile insurance card to the Properties & Risk Management Office,Attention: Risk Manager at riskmanager@charlottediocese.org to have a currentmotor vehicle record check (MVR) performed.

2. Must complete the “Defensive Driving Curriculum” and, if applicable, the “DrivingAdministrator Curriculum” online defensive driving courses through the CatholicMutual Group website. (Refer to the Online Training Instructions, Form 10.A).Usernames and passwords to complete this training will be provided bythe Diocesan Properties and Risk Management Department. Onlinemodules cannot be completed until the MVR check has cleared.

Note: It is the responsibility of the parish/school/location to have all approved drivers take the required online training courses and have a MVRS done every 3 years to remain an active Approved Driver.

If they will be driving children or youth on field trips, retreats, etc., they must have a clearedBackground Check and complete Safe Environment training. Contact the Diocesan HumanResources Office for additional information on these policies and procedures.

908 Ineligible to Drive Any Vehicle Related to Employment / Volunteer Service

No individual is to drive on behalf of any entity of the Diocese who have had any of the following citations or convictions in the past 3 years:

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Operating a vehicle during a period of license suspension, revocation or forfeiture

Driving under the influence of alcohol or drugs

Hit-and-run accident

Failure to report an accident

Negligent homicide arising out of the use of a motor vehicle

Using a motor vehicle for the commission of a felony

Operating a motor vehicle without the owner’s authority

Permitting an unlicensed person to drive

Reckless driving

A combined total of 3 or more accidents and/or convicted moving violations in the past3 years

909 Drivers of Bus Vehicles (School Bus or MFSAB)

909.1 Approval Procedures Required

All prospective drivers who drive a bus or a Multifunction School Activity Bus (MFSAB)to transport 10 or more passengers including the driver, must complete and submit theRequest for Approved Driver Status form (Form 9.A), along with a clear copy of theirCDL driver’s license with “S” and “P” endorsements to the Properties & RiskManagement Office, Attention: Risk Manager, so a current motor vehicle record check(MVR) may be performed, as well as the Criminal Background Release andAuthorization Form (Form 5.C)

Forward clear copies of the form and all of its required paperwork to the DiocesanProperties & Risk Management Office – Attn: Risk Manager at riskmanager@charlottediocese.org for a motor vehicle record (MVR) check;

The driver is required to provide and maintain a current Department of Transportationphysical certificate (not to exceed 2 years);

The pre-hire Department of Transportation Drug Test may be taken at a facilityapproved by the Diocesan Human Resources Department and evidence of test needsto be provided to MACS Transportation Director. (The parish/school/agency isresponsible for any cost);

Both the driver and his/her supervisor need to be trained on Department ofTransportation Drug and Alcohol Testing Policy. The driver will be subject to randomdrug and alcohol testing every year (note: unless the driver is already employed as adriver elsewhere and is covered by that employer’s program, the cost for the randomdrug test is the responsibility of the parish/school/agency);

A first aid certificate is required every 3 years (including CPR);

Have the driver complete and remain current on Safe Environment training (ProtectingGod's Children). Check with the Diocesan Human Resources Office for moreinformation on these policies and procedures.

Each day that the vehicle is driven, the Pre-Trip Inspection Form for Vans and Buses(Form 9.B) needs to be completed.

Note: An annual DOT inspection of all school buses must be performed.

Evacuation drills should be done at least twice a year for daily school routes.

Complete the “Be Smart–Drive Safe” and “Church Transportation, Is it Necessary &Ministry Based” online defensive driving courses through Catholic Mutual Group and

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provide a copy of the Certificate of Completion (refer to the Online Training Instructions, Form 10.A).

Note: Approved drivers are required to take these online training courses every 3 years.

910 Vehicle Types and Licensing Requirements

Employee and Volunteer Regular Class “C” License applies to:

Regular passenger vehicle such as sedan, SUV, pickup, etc.

9 or less passenger van

Employee and Volunteer Commercial Driver “CDL” License applies to:

Any driver who wishes to drive a school bus or Multifunction School Activity Bus(MFSAB).

Additional Requirements for Drivers of Vehicles Transporting 16 or More Persons

An “S” Endorsement (school bus endorsement) is required for any CDL driver transporting “parochial or any other type of pre-primary, primary, or secondary students from home to school, from school to home or to and from school sponsored events” in a school bus.

A “P” Endorsement (passenger endorsement) is also required for any CDL driver transporting adults and their families.

The state penalty for drivers who improperly drive without a CDL when so required is a possible fine of up to $2,500. In extreme cases, the fine can be as high as $5,000 and 90 days in jail. Employers are subject to these penalties as well if they knowingly allow a worker to operate a commercial motor vehicle without the proper license.

911 Chartered Van / Bus Requirements

Before any trips may be taken requiring our parishioners, students, teachers, parents and/or chaperones to be transported on a chartered bus/van requested and secured from a transportation company, a Certificate of Insurance should also be obtained, with liability limits of $1,000,000 to $5,000,000 depending on the size of the group transported.

911.1 Van / Bus Policy

Note: Effective July 1, 2003, new or used 11-15 passenger vans can no longer be purchased, leased, or utilized for the purpose of transporting passengers by any parish/school/agency.

Seat(s) cannot be removed from an 11-15 passenger van to reduce capacity.

Ten passengers or fewer cannot be transported in a 15-passenger van to qualify for a ten-passenger van.

Ten-passenger vans (or smaller) can continue to be used for parish/school/agency functions. When counting passengers, the driver is included.

11-15 passenger vans can be used for maintenance, hauling or other non-passenger carrying functions if all but the front 2 seats are removed.

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11-15 passenger vans can be replaced with either a school bus or a Multifunction School Activity Bus (MFSAB). An MFSAB is a vehicle which complies with the Federal Motor Vehicle Safety Standards (FMVSS) applicable to school buses for crash survivability and mirrors.

If an MFSAB is used for the transportation of children, these vehicles must meet FMVSS 111; FMVSS 220; FMVSS 221; and FMVSS 222 (see below). If purchasing an MFSAB to transport children, it is important to confirm with the seller that the vehicle meets all four FMVSS. There are vehicles that visually appear to be conforming, but are not.

When acquiring a bus or shuttle to transport adults, the four FMVSS should also be followed. However, CUP II may approve adult transportation for a nonconforming bus or shuttle that meets at least two of the FMVSSs in limited circumstances. Requests for exceptions should be submitted to Catholic Mutual Group.

Although MFSABs are preferred, mini-vans may continue to be used to transport children or adults. A mini-van is defined as a passenger vehicle designed to transport no more than 8 total occupants.

Below are the four FMVSS referred to in the above policy. Additional information on how to determine if a bus or shuttle meets FMVSS standards can be obtained from Catholic Mutual Group’s Risk Management Department at 1-800-228-6108.

FMVSS 111 – Fulfills the safety requirement for the rear-view and cross-view visibility

FMVSS 220 – Establishes requirements for the school bus body structure in rolloveraccidents

FMVSS 221 – Regulates the strength of body panel joints in school buses

FMVSS 222 – Establishes occupant protection requirements for school buspassenger seating and barriers

Due to the lack of safety features built into the vehicle, parishes/schools/agencies should not own or operate motor coach buses.

Drivers of all vehicles, especially buses, need to be aware of the difference in handling of the vehicle when loaded. Some of the techniques on managing this risk include:

Avoid sharp turns unless speed is kept low.

Avoid abrupt maneuvers.

Only use high-quality tires with good tread and maintain proper tire air pressure.

Keep the fuel tank full.

Fill front seats first.

Never place any cargo on the roof rack.

Make sure all passengers are buckled up. Their safety in a small vehicle is built aroundthe belt system.

Downshift the transmission when traveling downhill to keep from overheating yourvehicle brakes.

912 Maintenance

Reliable vehicles are equally as important as qualified drivers in the quest for safe transportation. Failure to provide or maintain quality vehicles for transporting people can be a primary reason for a tragic accident.

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Equip vehicles with basic safety kits such as a set of emergency triangles (flares are no longer legal), jumper cables, flashlight, first aid kit, tools to change a tire, ice scraper in winter, extra set of keys, fire extinguisher, etc.

913 Additional Requirements

North Carolina law requires that you keep a current auto insurance identification cardand registration in your vehicle at all times.

Keep in your glove compartment a folder containing a copy of the Report of AutomobileAccident form (Form 9.C), along with a pencil or pen.

Daily check fluids, tires, lights, signals, wiper blades, seat belts, hoses, brakes, horn,mirrors, etc.

Notify your supervisor of any problems.

Fill the vehicle with gas when 1/4 tank or below.

Clean all materials, waste paper, drink cans, etc., out of the vehicle when returning aChurch vehicle.

914 Record Keeping

914.1 Approved Drivers

Records pertaining to approved driver selection and ongoing required training (online or otherwise) is the responsibility of the parish/school/agency and such records should be kept on file for 3 years following termination of driving privileges.

914.2 Requirements for all owned buses and vans

A detailed annual vehicle safety inspection is required for all vehicles and these recordsneed to be maintained. A certified Department of Transportation (DOT) inspection isrequired on all buses over 16-passenger capacity.

A mandatory pre-trip inspection is to be performed each day the van/bus is used.Records of these inspections are to be maintained. Refer to the Pre-Trip InspectionForm for Vans and Buses (Form 9.B)

A preventative maintenance inspection should be conducted every 6 months to findproblems not discovered during the pre-trip inspection.

Keep annual driver training records of all drivers on file while verifying online safe drivertraining requirements are met.

Keep accident records so that they can be analyzed to determine accident trends andcauses.

Keep maintenance file of all repairs, work orders, etc., even replacing lights.

Keep contracts with an outside transportation company.

915 Accident Investigation

Employees must report any accident, theft, damage, breakdown, or mechanical problem involving a parish/school/agency vehicle or a personal vehicle used on parish/school/agency business to their supervisor, regardless of the extent of damage or lack of injuries. These reports must be made as soon as possible but no later than 24 hours after the incident. Employees/volunteers are expected to cooperate fully with authorities in the event of an

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accident. However, they should not make any statements other than in reply to questions of investigating officers. Report the accident to the employee’s supervisor within 24 hours and complete and submit to Catholic Mutual Group the Report of Automobile Accident form (Form 9.C).

916 Claims Procedures for Automobile Losses

New automobile losses are to be called into Catholic Mutual Group's toll-free reporting line 1-855-807-3262. Calls are taken 24 hours a day. The caller will be instructed that the Sr. Auto Claims Representative (Linda Loney) will contact them within the next 24 business hours. If this is a serious accident with injuries or fatalities, the Auto Claims Representative, will be notified immediately to start an investigation.

After contact has been made, if an independent adjuster is needed the adjuster will be assigning the claim out to Property Damage Appraisers. They will make contact with the appropriate party, inspect the vehicle and forward the report back to Catholic Mutual Group.

If this is a minor accident, the adjuster will be asking for the location to get one estimate on the vehicle and forwarding to Catholic Mutual Group for review.

On a Comprehensive and Collision claim: The adjuster will pay the claim less your deductible and forward the check to the location where the vehicle is at. Total losses: the adjuster will have a salvage company come and pick up the assured vehicle, request the title from the location, and sell the vehicle. The salvage payment on the vehicle will reduce the loss amount that was paid on the claim.

On third party claims: The adjuster will contact the claimant and get estimates on the damage to their vehicle. If it is a total loss or extensive damage, the adjuster will assign out to an independent auditor for inspection. The adjuster will handle all settlements directly with the third party.

Subrogation: The adjuster will pursue them at-fault party for all damages that were paid to our assured. This will include our assured deductible. Once we collect the monies back, we will reimburse our assured there deductible.

Legal contacts at Catholic Mutual Group:

Collin Liston - General Counsel Ph: 402-514-2405

Michael Lee - Corporate/Claims Compliance Director Ph: 402-514-2412

917 What to do in Case of an Accident

Check for injuries and administer first aid where possible.

Do not move the vehicle.

Have a responsible person call the police.

Protect the accident scene with a set of emergency triangles or reflectors, which shouldbe placed a minimum of 100 feet either direction from the accident.

Keep children calm and in the vehicle unless danger of fire exists.

Obtain information from other driver(s) and witnesses, including names, addresses,telephone numbers, driver’s license number, vehicle license plate, description ofvehicles and other party(s) insurance company and policy number.

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Do not admit liability. The insurance company will investigate and determine whetherthere is liability on our part.

Do not leave the accident scene until told to do so by the police.

Be sure to get the accident report number from the police.

If the accident involves a 16-passenger or larger bus, the driver must comply with theDepartment of Transportation Drug and Alcohol Testing Policy.

918 Safety Tips

The demands of safe driving are constantly changing. To be a safe driver, one must be aware of everything that is happening around them in order to have as much time as possible to react.

Obey all traffic laws. Motor vehicle laws are enacted for your safety. Take advantageof their protection.

Every driver should have a practice run in the vehicle they will drive prior to the actualtrip.

Prior to the trip, discuss with the drivers any plans for handling emergencies. How tohandle bad weather or driving conditions? If traveling in a caravan, what will the signalbe if someone needs to stop immediately?

Every driver needs written directions (including a map and phone number) to thedestination. Also include money needed for gas or tolls and any special instructionsabout the trip, such as planned stops to eat or use the restrooms.

If possible, fuel vehicles only when passengers are not on board.

Emergency evacuation procedures need to be explained before leaving on a trip.

Children under 8 years of age must ride in an approved child or booster seat.

Make sure everyone in your vehicle buckles up. More than 9,000 lives could be savedeach year in the U.S. alone if we all did. Most crashes occur at speeds below 40 mph.If you are unbelted in a crash at the slow speed of 30 mph, you can hit the windshieldwith the same impact as if you’d jumped from a three-story building. Safety belts keepyou inside the vehicle during a crash. If you are ejected, you are four times more likelyto be killed. Less than 1/2 of 1 percent of injury-producing crashes involves fire orsubmersion. But if fire or submersion occurs, you’re more likely to be unhurt, alert andcapable of escaping quickly if you are wearing a safety belt.

The driver should never consume food or drink while the vehicle is moving. Wait untilyou come to a stop to change the music, take a bite or a sip, or talk on the cell phone.

The vehicle should not be overloaded.

There should never be any smoking in the vehicle.

Safety considerations include the availability of sidewalks, safe crossings atintersections and safety from physical attack.

Maintaining a safe following distance also minimizes the braking and accelerationneeded. Leave at least 4 seconds of space between you and the vehicle ahead.

Take extra care when backing up. If you do not have a clear field of vision, havesomeone help guide you.

Slow down; speeding is one of the leading causes of fatal accidents.

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Take extra care when fatigued or stressed.

If a vehicle becomes disabled, either have all occupants stay in the vehicle or leave thevehicle and stay well away from the vehicle at a safe distance. Never stand behind adisabled vehicle. Many drivers and passengers have been injured because they stoodaround or behind a disabled vehicle and were struck by other vehicles.

Perform passenger check-ins and check-outs to ensure no one is left behind.

Note: Aggressive driving is a traffic offense or combination of offenses such as followingtoo close, speeding, unsafe lane changes, failure to signal intent to change lanes, andother forms of negligent or inconsiderate driving.

REQUEST FOR APPROVED DRIVER STATUS(Return Completed Form to Parish/School/Agency)

Employee Volunteer Priest

TO BE COMPLETED BY PARISH/SCHOOL/DEPT STAFF – ALL items must be completed

Requesting Parish, Agency School or Department (Include City):

Name & EMAIL of Requesting Official:

Driver’s Information (To Be Completed by Driver): PLEASE PRINT CLEARLY

Name:

Street Address:

City: State: Zip:

Home Phone: Cell Phone:

Email (DO NOT LEAVE BLANK):

Date of Birth: / _/

Driver License # License Expiration Date: / /_

Attach Proof of Insurance Here(copy of insurance card)

Attach COLOR Copy of Driver License Here

School bus drivers must provide a copy of

their CDL license with “S” & “P” endorsements

I am aware that the Diocese of Charlotte will request a copy of my driving record from the North Carolina Department of Motor

Vehicles, and may revoke my permission to drive for the Diocese at any time if there is any additional reportable offences.

Signature Date

Permission granted by Diocese to drive a:

Risk Management and Insurance Manual – March 2018 Form 9.A

Comments:

/ / Date:

By: DIOCESAN USE ONLY

: Personal Vehicle

_ : School Bus, School Activity Bus or Van

_: Church Activity Van

: CDL

Deacon Seminarian Religious

Risk Management and Insurance Manual – March 2018 Form 9.B

PRE-TRIP INSPECTION FORM FOR VANS AND BUSES

RETURN COMPLETED FORM TO PARISH/SCHOOL/AGENCY

An inspection should be performed each time the vehicle is used. Check each item unless it is defective. Record defects at the bottom of this sheet. Report defects to your administrator or pastor for prompt correction.

Parish/School/Agency:

Date: Odometer Reading:

Step One: Walk-up Notes

□ Check for flat tires, missing valve caps, worn or damaged tires

□ Check for any new exterior damage

Step Two: Equipment Check

□ First aid kit

□ Fire extinguisher

□ Registration / Insurance I.D. Card and Insurance Accident Kit

□ Blanket and snacks (for Winter Breakdowns)

□ Spare tire

□ Tire jack, include block of wood on which to place jack

□ Emergency Triangles

□ Snow Chains

Step Three: Interior Check

□ Test horn

□ Test wipers and washer fluid

□ Check for seat belt damages

□ Buses: Check Seat Backs for damage, stability, loose/protruding parts

□ Open/check emergency door (if applicable)

□ All switches operating properly

□ Sun visors/shields in place

□ Dashboard clear of movable items/objects

□ Fuel level adequate

□ Oil pressure

□ Parking Brake functioning properly

Step Four: Exterior Check

□ Check headlights, signals, brake lights and hazard lights

□ Hood latched

□ All mirrors functional

□ Windshield clear and clean (not excessively cracked)

□ Exhaust system hanging properly

□ Fuel cap in place

□ Check under vehicle for fluid leakage

□ Check under vehicle for axle damage

□ Check brake fluid and power steering fluid

Defect / damages noted:

Corrective action taken:

Signature:

Risk Management and Insurance Manual – March 2018 Form 9.C

REPORT OF AUTOMOBILE ACCIDENT

NOTIFY CATHOLIC MUTUAL GROUP IMMEDIATELY AT REPORTACLAIM@CATHOLICMUTUAL.ORG AND RISKMANAGER@CHARLOTTEDIOCESE.ORG

PARISH/SCHOOL/AGENCY:

ADDRESS:

PHONE #: E-MAIL:

DATE OF ACCIDENT: (MM/DD/YYYY) TIME OF ACCIDENT:

LOCATION OF ACCIDENT:

WERE THE POLICE CONTACTED? □ YES □ NO

IF YES, WHICH JURISDICTION? REPT. #:

VEHICLE: YEAR MAKE VIN

DRIVER: EMPLOYEE: □ YES □ NO

PHONE #: WERE THERE ANY INJURIES? □ YES □ NO

IF YES, PLEASE DESCRIBE:

WAS VEHICLE DAMAGED? □ YES □ NO

IF YES, DESCRIBE DAMAGE:

IS THE VEHICLE DRIVABLE? □ YES □ NO

IF NOT, WHERE IS IT LOCATED?

OWNER OF OTHER VEHICLE OR PROPERTY:

DRIVER OF OTHER VEHICLE:

INSURANCE CO.: POLICY NO.:

VEHICLE: YEAR MAKE PLATE NO.:

WAS OTHER VEHICLE DAMAGED? □ YES □ NO

IF YES, DESCRIBE DAMAGE:

WERE THERE ANY INJURIES? □ YES □ NO

IF YES, PLEASE DESCRIBE:

WITNESSES / PASSENGERS:

REPORTED BY:

PHONE #: DATE:

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Risk Management and Insurance Manual – March 2018 Form 9.C (2)

DESCRIBE WHAT HAPPENED IN YOUR OWN WORDS. (YOU MAY USE DIAGRAMS IF NECESSARY)