VEMA Accident Report	MPI Claim Number MPI Claim Number	MPI Adjuster Name and Phone (if known) MPI Adjuster Name (if known)
Unit Number NNNNN	Date of Accident MM/DD/YY
Location Accident Location
If you’re in an accident . . . Call Police if: A person is injured or there is a fatality. Your vehicle has been vandalized or subject to a hit and run or theft. The other driver is uninsured or driving with a suspended license. The other driver is impaired.	Call MPI at 204-985-7000 or Toll-Free 1-800-665-2410 (outside of Winnipeg) to open a claim. Record your claim number above. Call VEMA at 1-800-363-6693 to report your accident. Send a copy of this form and any supporting pictures to VEMA Mail: 626 Henry Ave., Winnipeg, Manitoba R3A 1P7 Fax: 204-957-1109 Email: vemainfo@gov.mb.ca (forms are available at www.vema.gov.mb.ca) If applicable, forward copies of your completed form to your insurance officer, supervisor or appropriate organization contact

Organization

Organization/Branch Organization / Branch	VEMA Customer Number Customer Number
Address Full Address including Postal Code
Phone 204-NNN-NNNN	Fax 204-NNN-NNNN	E-mail user@gov.mb.ca

VEMA Vehicle

VEMA Unit Number NNNNN	License Plate Number ABC123	Make/Model Make and Model

Driver

Name Driver Name	Driver’s License Number LL-LL-LL-LNNNLL	Driver’s License Expiry Date MM/YY
Day Phone (204) - NNN-NNNN	Evening Phone LL-LL-LL-LNNNLL	Fax LL-LL-LL-LNNNLL	E-mail user@server.name
Name of Immediate Supervisor Name of Supervisor	Phone Number of Immediate Supervisor (204) - NNN-NNNN

Occupants – Total Number of Occupants: _ NN _ (not including driver)
(Please attach a separate sheet if more than one occupant was involved)

Name Occupant Name	Address Full Address including Postal Code
Day Phone (204) NNN-NNNN	Evening Phone (204) NNN-NNNN	Fax (204) NNN-NNNN	E-mail user@server.name

Other Vehicles and Drivers – Total Number of Vehicles Involved: NN (including your VEMA vehicle)
(Please attach a separate sheet if more than two vehicles were involved)

License Plate Number ABC 123	Province/State of Plate Manitoba	License Expiry Date MM/YY
If Not Manitoba Plates—Name of Insurance Company Name of Insurance Company	If Not Manitoba Plates—Policy Number Policy Number	If Not Manitoba Plates—Name of Agent and Address Name of Agent and Address
Year and Make Year and Make	Model Body Type: Sedan, Mini Van, etc.
Driver’s Name Driver Name	Driver’s License Number LL-LL-LL-LNNNLL	Driver’s License Expiry Date MM/YY
Address Other Driver's Full Address with Postal Code
Day Phone (204) NNN-NNNN	Evening Phone (204) NNN-NNNN	Fax LL-LL-LL-LNNNLL	E-mail user@server.name
Vehicle Owner’s Name (if not Driver) Name of Owner	Address Other Vehicle Owner's Full Address with Postal Code
Day Phone (204) NNN-NNNN	Evening Phone (204) NNN-NNNN	Fax LL-LL-LL-LNNNLL	E-mail user@server.name

The Accident

Date MM/DD/YY	Time (AM/PM) NN:NN AM/PM	Location Location of Accident	At the time of the accident was the vehicle being used for: (click to mark) Business Personal use
Light Conditions Dawn, Day, Dusk, Dark	Weather at Time of Accident Weather, clear, cloudy, rain, snow, fog, ice	Type of Road Surface Road Surface	Road Condition Road Condition
Name of Witnesses (other than occupants) Name<s> of Witness<es>	Witness Phone (204) NNN-NNNN	Witness Address Witness's Full Address with Postal Code
Had You Consumed any Drugs or Alcohol? (Click to mark box) Yes No	If so, How Much Quantity of drinks and type	When When Consumed
Did the Other Driver Appear to Have Been Impaired? Yes No	Give any Details Details
Direction of Vehicle Direction	On What Road? Name of Road	What Side of Road? Side of Road	Speed NNN km/h
Direction of Other Vehicle Direction	On What Road? Name of Road	What Side of Road? Side of Road	Speed NNN km/h
What Traffic Signals Were Present? Traffic signals present
Did you Give A Warning Signal? Yes No	What Kind? Kind of Warning	Which Lights Did You Have On (if any)? Lights on
Did the Other Driver Give A Warning Signal? Yes No	What Kind? Kind of warning	Did the Other Driver Have their Headlights On? Yes No
Has the Accident been Reported to Police? Yes No	Did Police Attend the Scene of the Accident? Yes No	Name of Police Force Police Force Name
Police Officer’s Name Officer's Name	Police Phone (204) NNN-NNNN	Police File Number File Number
Have the Police Charged Anyone? Yes No	Name of Person Charged Name Charged Person	Nature of Charge Nature of Charge

Injuries and Damage (please attach a separate sheet if you require more room.)

Nature of Damage to other Vehicles Nature of Damage - other vehicle
Nature of Injuries to Drivers or Occupants Nature of Injuries
Nature of Damage to Unit Nature of damage to Unit

Driver’s Detailed Description of How Accident, Loss or Mechanical Damage Occurred

Driver’s Detailed Description of How Accident, Loss or Mechanical Damage Occurred
State Cause of Accident State cause of Accident
Driver Signature	Date MM/DD/YY

VEMA USE ONLY

Preventative and Corrective Action
VEMA Vehicle Deductible	Maximum Insured Value

N If helpful, illustrate the accident at right. Be sure to note:

The name of all streets,

Course of all cars involved, and

Position of vehicles at instant of accident.

626 Henry Avenue, Winnipeg, Manitoba R3A 1P7

Phone: 1-800-363-6693	Fax: 204-957-1109

Copies of this form are available at www.vema.gov.mb.ca

Last Revision Date: June 26, 2013