IF YOU ARE INVOLVED IN AN ACCIDENT

2. Call for EMERGENCY HELP if someone is HURT.

3. TAKE names, addresses & phone numbers of all WITNESSES: Including people in other vehicles involved.

licensed authority: Such as a POLICE OFFICER.

YMUS VEHICLE:

Driver:Name Address City State Zip Phone #

Employed By: YMMC 1000 Hwy 34 E Newnan GA 30265

Address City State Zip

THE ACCIDENT:am Street & Nearest Cross Streetpm

Direction you were driving: Speed How far from Right curb were you? Headlights ON?Yes [ ] No [ ]

Describe Weather Conditions: Describe Road Conditions:

Was accident reported to police? Officer Name: Badge # Which Police Dept. Police Report #

Describe how accident happened:

Did the Vehicle (#1) contribute to the accident?

Describe Damages:

DIAGRAM:Fill in street names. Indicate directions in which the vehicles were going* Draw a diagram using:

# 1 Your Vehicle (# 1) # 2 Other Vehicle/s (# 2, etc.)

*Mark points of compass (N-S-E-W)

SEE OTHER SIDE

1. STOP IMMEDIATELY - CALL A POLICE OFFICER

4. COMPLETE this report AT THE SCENE OF THE ACCIDENT. Fill in ALL information asked for.

5. DO NOT give any information concerning accident, other than your Insurance ID Card, to anyone UNLESS they have

6. REPORT ACCIDENT IMMEDIATELY to your SUPERVISOR and to the YAMAHA FLEET ADMINISTRATOR

Bobbi-Ext. 4111 Cell (678) 296-0978 John Allison (714) 761-7459 or Genevieve Monreal (714) 761-7765 / FAX # (714) 761-7840

Year Make Model Vehicle I.D./Vin # License #

Company (YMUS, YMMC, YGC, Boat Co., etc.)

Date: Hour:

City: State:

N [ ] S [ ] E [ ] W [ ]

Yes [ ] No [ ]

Yes [ ] No [ ]

IF YOU ARE INVOLVED IN AN ACCIDENT

DAMAGE TO PROPERTY OF OTHERS:Owner's Name: Address: Phone #

Driver's Name: Address: Phone #

2

3Description of other vehicle/s: Describe damages to other vehicle/s:

1 Year Make Model

I.D.# / Vin# License #2 2 Year Make Model

I.D.# / Vin# License #3 3 Year Make Model

I.D.# / Vin# License #

INJURED PERSONS:Name: Address: Phone #

1 ( )

2 ( )

3 ( )Describe injuries: Where was injured person taken after accident?

1

2

3

WITNESS INFORMATION:Name Address: Phone #

1 ( )

2 ( )

3 ( )

XSIGNATURE

In order to process your claim quickly please FAX "Cost to Repair" estimates from a body shop as soon as possible to Genevieve Monreal / Fleet Support (714) 761-7840.

Please forward signed Original to:ATTN: VEHICLE SUPPORTYMUS6555 KATELLA AVECYPRESS CA 90630