Form Doa 6496 – Fill Out and Use This PDF

The DOA-6496 form is a critical document utilized by the Wisconsin Department of Administration for reporting accidents or incidents involving state-owned vehicles. It mandates detailed reporting from the driver and swift submission to the appropriate supervisors and fleet offices, ensuring all necessary steps are taken post-accident. If you’re involved in an incident with a state vehicle, understanding how to properly fill out this form can help streamline the process.

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Form Doa 6496 PDF Details

The Wisconsin Department of Administration's DOA-6496 form plays a critical role in the management and reporting of incidents involving state-owned vehicles. Specifically drafted for situations where a government vehicle finds itself in an accident, this comprehensive document serves as a procedural guide for drivers to ensure all necessary steps are followed promptly. Key elements outlined in the DOA-6496 include immediate reporting to local law enforcement to secure an officer's report, notifying supervisory personnel and the fleet manager, and the timely submission of the completed and endorsed form to the relevant Fleet Office. Additionally, the form contains sections for detailed vehicle information, the accident's specifics, involved parties' details, and a narrative segment for the driver's account of the incident, further supplemented with instructions for when a police report is not available but damages or injuries surpass specified thresholds. This systematic approach is designed to streamline the reporting process, ensure accurate documentation of incidents, and facilitate the efficient management of state vehicle assets and related insurance claims.

Question	Answer
Form Name	Form Doa 6496
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	dotted, Seatbelt, citations, doa form

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Wisconsin Department of Administration	Vehicle Accident/Incident Report
DOA-6496 (R08/2000)

Bureau of State Risk Management

Instructions:

In case of an accident involving a state-owned vehicle, the driver of the vehicle must:

1.Report the accident promptly to a local law enforcement agency and obtain a copy of the officer’s report.

2.Contact your supervisor and fleet manager as soon as practical to report the accident.

3.Within 24 hours of the accident, submit this completed & signed form to your supervisor.

4.Submit this completed form, signed by your supervisor, to the appropriate Fleet Office within 48 hours.

5.If the police do not respond or complete the accident report and the accident has caused bodily injury, vehicle property damage is $1,000 or more and/or government-owned property damage is $200 or more the driver must submit a completed MV-4002 Driver’s Report of Accident to the Department of Transportation within ten days. Forward a copy to the fleet office.

Agency/Dept.

Location

Location of the

Accident

State

Vehicle

Information

Assigned

Pool/

Functional

Information

Driver

State

Vehicle

Other

Party(s)

Involved

(add additional sheets if more than one other party involved)

Agency/Department Name

Division/Institution/Campus

Agency Number

Supervisor’s Name

Phone Number (

)

Street Address

City

ZIP + 4

Street/Highway

Accident Date (mm/dd/ccyy)

City

County

State

Accident Time

State Vehicle Owner Agency/Dept. Name

Reason for Vehicle Use

Year

Make/Model

Body Type

Mileage

Color

Fleet Number

Vehicle Identification Number

License Plate Number

Describe Parts Damaged

Circle numbered areas of vehicle damage.

Front

Rear

Driver Name

Driver Injured

Home Phone (

)

Work Phone (

)

Wearing Seat Belt

Email Address

Date of Birth

Driver’s License Number

Work Address

City

State

ZIP + 4

Home Address

City

State

ZIP + 4

Were There Passengers in This Vehicle?

Yes

Injuries

Wearing Seat Belt

If Yes, List Names: ______________________________________________

Yes

______________________________________________

Yes

(Please indicate what type of

Describe Parts Damaged

If automobile, circle numbered areas of

property was damaged.)

vehicle damage.

automobile

Front

fence

Rear

building

guard rail

other

Property Owner (if different from driver)

Home Phone

(

)

Work Phone (

)

Home Address

City

State

ZIP + 4

Year

Make/Model

Body Type

License Plate Number

Vehicle Identification Number

Insurance Company

Phone (

)

Agent Name

Address

Driver Name

Driver Injured

Home Phone (

)

Work Phone (

)

Wearing Seatbelt

Home Address

City

State

ZIP + 4

Driver’s License Number

Were there passengers in this vehicle?

Yes

Injuries

Wearing Seat Belt

If Yes, List Names: ______________________________________________

Yes

______________________________________________

Yes

DOA-6496 (R08/2000)

Pg. 2 of 2

Was the accident investigated by a law			Were photographs taken at the scene?		By whom?
enforcement agency?
	Yes	No	Yes	No

Name of the Investigating Officer			Law Enforcement Agency Name			Case Number

Were citations issued?			To whom?
	Yes	No

Road Conditions			Did the state vehicle have lights on?		Did the other vehicle have lights on?
Wet	Dry	Icy	Yes	No	(if other vehicle involved)
Wet	Dry	Icy	Yes	No	Yes	No
			Bright	Dim	Yes	No
Other			Bright	Dim	Bright	Dim
Other					Bright	Dim

At what speed were you (state vehicle) traveling?

At what speed was the other vehicle traveling?

Posted Speed Limit

What traffic controls were in effect?

For whom?

Who had the right of way?

What signals were given by you?

What signals were given by the other driver?

What did you do to avoid the accident?

What did the other driver do to avoid the accident?

Witness

Information

Name of Witness

Home Address

City

	Phone Number (	)
State	ZIP + 4

Driver Description of the Accident/Incident

Attached sheets include additional description, witness and passenger information.

Please complete this diagram. Indicate names of streets, direction, position of vehicles and point of contact. Use a solid line to show path before the accident and a dotted line to show path after the accident.

		1		State Vehicle
		2		Other Vehicle
		3		Third Vehicle
				Pedestrian
			Indicate North
			Indicate North
				Stop Sign
				Stop Sign
				Yield Sign
				Stop Light

			Scope of Employment Statement
As the driver of the state owned vehicle described in this report, I		As supervisor of this position, I affirm that the individual named
acknowledge that all information provided is true and accurate to		driver was operating the vehicle within his or her authorized scope
the best of my knowledge.		of employment at the time of the accident.		Yes	No

Signature of Driver (Required)	Date (mm/dd/ccyy)	Signature of Supervisor (Required)		Date (mm/dd/ccyy)

Form Doa 6496 – Fill Out and Use This PDF

Form Doa 6496 PDF Details

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