motorized utility vehicle (muv) policy documents

MOTORIZED UTILITY VEHICLE (MUV) POLICY DOCUMENTS

Attached to this cover sheet are:

• MUV Administrative Policy & Procedures• MUV Statement of Understanding• MUV Accident Reporting Policy• M.U.S.I.C. Motor Vehicle Loss Reports (two copies)

All supervisors, department heads, etc., and their employees must read the MUV Policy and Procedures and sign the Statement of Understanding (SOU). Departments must keep signed SOUs for all employees and send copies to Risk Management, Environmental Health & Safety, Motor Pool 1303A West Campus Drive.

Additionally, anyone driving a University MUV must have his/her driving record checked and approved annually by Risk Management, Environmental Health & Safety prior to operating an MUV.

If you have any questions or need additional information, please contact:

RISK MANAGEMENT/ENVIRONMENTAL HEALTH & SAFETY

Motor Pool 1303A West Campus Drive

774-3741 or 774-7398

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MANUAL OF UNIVERSITY POLICIES PROCEDURES AND GUIDELINES

Number: 3-41 Page 1 of 4

Authority: George E. Ross, President History: New policy Indexed as: MUVs; Gators; Rangers;

Title/Subject: OPERATION OF MOTORIZED UTILITY VEHICLES Applies to: faculty staff students student employees visitors contractors

Effective Date of This Revision: April 2016 Contact for More Information: Safety Administrator – Risk Management, Environmental Health & Safety

Board Policy Administrative Policy Procedure Guideline

BACKGROUND With the rising cost of gas and the increasing need to transport objects and equipment across campus in a timely and efficient manner, CMU has authorized the purchase and operation of Gators, Rangers, and other Motorized Utility and Low Speed vehicles to perform these tasks. PURPOSE The purpose of this Policy is to bring CMU into compliance with relevant portions of federal law; the Michigan Motor Vehicle Code; and any relevant local law; and to ensure that these MUVs are operated in a safe and efficient manner, and that they do not interfere with the orderly operation of CMU or campus life. Further, the purpose of this Policy is to safeguard the pedestrians and other members of CMU’s campus community, as well as any members of the community at large who are present on CMU’s campus, sidewalks, and roadways. POLICY This policy establishes rules for the use of all Motorized Utility Vehicles (MUVs), and also to those motorized vehicles defined as Low Speed Vehicles (LSVs) by the National Highway Safety and Traffic Administration (NHSTA) Standard 500 (49CFR Part 571.500), as incorporated into the Michigan Motor Vehicle Code (collectively. “MUVs”). This policy does not apply to any non-MUV or LSV that is licensed for operation on Michigan roads, or to non-MUV heavy equipment (i.e. backhoes, bulldozers). Each excluded vehicle type is covered by other operational policies or laws governing their usage. MUVs used in support of Central Michigan University sponsored activities include, but may not be limited to: golf carts, Gators, Mules, Rangers, and Toro vehicles. The intent is to establish proper safety procedures and practices, as well as promote and provide for a safer environment for students, faculty, staff, and visitors. All visitors wishing to operate an MUV on CMU’s campus shall provide written assurance that they have read, understand, and will abide by this Policy. PROCEDURE All members of Central Michigan University’s community are governed by this policy (faculty, staff, students, student employees, visitors, contractors). Any new vehicle acquisitions must meet the minimum safety features found in NHSTA Standard 500. All MUVs purchased by CMU after the adoption of this policy must have a top speed of 20 MPH or have governors installed so that their aftermarket top speed is 20 MPH. In certain limited cases, an MUV must have a larger capacity and top speed (for snow removal, equipment hauling, or the like). In these instances, such MUVs can only be purchased after obtaining approval from the appropriate VP. All vehicles must be equipped with “turf tires,” rather than off-road or other types of tires. Vehicles owned by contractors and other non-affiliated departments, companies, corporations, etc., and operated on University property must also meet Standard 500. Any Department that wishes to purchase an MUV for that Department’s use must acquire the MUV through CMU’s Purchasing Department, and the MUV must conform to the standards and requirements contained in this policy before purchase. Once an MUV is obtained, Purchasing will notify CMU’s office of Risk Management to ensure that the MUV

Number: 3-41



Title/Subject: OPERATION OF MOTORIZED UTILITY VEHICLES

conforms to the standards and requirements contained in this Policy, as well as any requirements for the MUV contained in the Michigan Motor Vehicle Code with respect to its titling, licensing, and operation. Presently, there are three types of MUVs operating on CMU’s campus. The first group (“Group A”) consists of those MUVs that have a top speed of 20 MPH or less. These MUVs are considered ATVs by both state and federal law and thus cannot operate on public roadways. They must be operated “off road,” and do not need to be titled or licensed by the state. The second group (“Group B”) has a top speed of between 20 and 25 MPH. This group is subject to both state and federal law as “low speed vehicles” and can only operate on roads with posted speed limits of 35 MPH or less. They must be properly titled and licensed by the State of Michigan. The final group (“Group C”) consists of MUVs with a top speed that exceeds 25 MPH. These are subject to Michigan law as passenger vehicles and can only be operated on streets and roadways. They must not operate on sidewalks or grounds. They must be properly titled and licensed by the State of Michigan. Any and all MUVs that operate on CMU campus or property must prominently display a letter (A, B, or C) that corresponds to its designation as outlined in the previous paragraph. This letter shall be placed on the hood, on either side, and on the rear of the MUV. CMU shall provide temporary letter identifiers for visitors so that their MUVs can be identified appropriately. All operators of MUVs (including operators who are visitors) must meet the following criteria before operating a vehicle on property under the jurisdiction of Central Michigan University:

Operator Requirements: 1. Must possess a valid Michigan driver’s license. Full-time, out-of-state student employee/operators who have a

valid driver’s license from their state are exempted from the requirement of obtaining a Michigan driver’s license. 2. Must be at least 18 years of age. 3. Must pass a driving record check conducted by RMEHS. 4. Must have effective use of all 4 limbs unless vehicle is modified. 5. Must have coordination between eyes, hands, and feet. 6. Must have freedom from known convulsive disorders or episodes of unconsciousness. 7. Must read the owners manual and any individual manuals that pertain to attachments. 8. Must have the ability to understand signs, labels, and instructions. 9. Must have completed a Central Michigan University sponsored MUV Safety Training Program. Training will

include the signing of CMU’s Statement of Understanding. Contractors/visitors: See #2 under Vehicle Operation Requirements.

Vehicle Operation Requirements: 1. An operator is accountable for ensuring that his/her own operation of MUVs is performed safely and within the

parameters of this policy. Unsafe operation of MUVs can result in serious injury and/or death to the operator, passengers, or other persons.

2. CMU is not responsible for training contractors and/or visitors who operate MUVs; however, all contractors and/or visitors wishing to operate an MUV at CMU must sign a Statement of Understanding/Acknowledgement before operating an MUV on CMU property.

3. Operators must yield the right-of-way to pedestrians AT ALL TIMES. Operators are not to block the path nor limit pedestrian access on walkways.

4. Operators are to be diligent and pay particular attention to the needs of disabled persons, as limitations in vision, hearing or mobility may impair their ability to see, hear, or move out of the way of MUVs.

5. CMU MUVs will not be operated on public roads or highways, except as designated below. All operators are prohibited from operating MUVs outside the boundaries of the University or any public thoroughfare immediately adjacent thereto.

6. Seat belts must be worn by operators and passenger if equipped with such. 7. Operators must use directional or hand signals before making a turn. 8. Operators must not overtake another MUV that is also in motion.




9. The speed limit for all MUVs not travelling on a street, parking lot, or any area not commonly traversed by pedestrians, is 10 mph; however, when pedestrians are present, the speed limit is 5 mph (approximately the speed of a brisk walk). Operators are to use due caution in crosswalks. MUVs using pedestrian crosswalks do NOT have the right-of-way. Use only marked pedestrian crosswalks when crossing public streets and roadways.

10. The name of the CMU department and department identification number, along with the letter designation of the MUV type (see above) must be prominently displayed on CMU MUVs. Anyone who observes reckless or inappropriate operation of an MUV should notify the department supervisor, CMU Police, or Risk Management and Environmental Health and Safety (RMEHS).

11. An operator (whether CMU, contractor, or visitor) must immediately report any accidents to CMU Police and to the operator’s supervisor (if the MUV is a CMU MUV). CMU Police will forward MUV accident information to RMEHS. Any and all injuries to CMU employees or student employees caused by or related to operation of a CMU MUV must be reported to CMU’s Workers Compensation hotline at (989) 774-7177.

12. All vehicles must have the slow moving vehicle symbol (reflective orange triangle) prominently displayed on the rear of the vehicle.

13. All vehicles must be equipped with “turf tires,” rather than off-road or other types of tires. 14. No operator shall wear radio or music headphones, or talk on, text with, or otherwise use cell phones while driving.

Safe service and operation requires an operator’s full attention. 15. An operator shall never operate an MUV while standing; operators must keep hands, arms, feet, and legs inside of

the vehicle when in motion. 16. An operator shall never operate the MUV with the cargo box raised. Exceptions: when it’s necessary to raise the

cargo box while driving to spread a load, for example, as with Landscape Operations. 17. Seating is provided for operator and appropriate passengers only; riders in the cargo box or other areas where seats

are not provided are prohibited. 18. Operators must avoid sudden starts, stops, or turns. 19. Operators must always use a level turn around area. 20. Operators must always set the parking brake when not in transit. 21. Operators are responsible for an MUV’s ignition keys for the period of time in which they are using the MUV.

Keys must be removed from all unattended MUVs. 22. No operator shall operate any MUV after sunset, unless the MUV is equipped with head and tail lights, and such

lights are illuminated during operation. 23. The MUV’s pay load is rated on level ground; refer to manual for specific model load limits. 24. Operators must be sure that any load is evenly distributed and securely anchored to avoid shifting. Cargo must not

protrude from the sides of the MUV. 25. Operators must never load above the load guard. 26. When driving on uneven terrain, operators must reduce the load and the MUV’s speed to maintain stability. 27. Operators must follow guidelines for proper handling of all fuels, waste products, and chemicals. 28. Operators must never store MUVs in non-approved areas such as a residential facility. 29. Operators shall not drive an MUV while under the influence of alcohol, illegal drugs, medications, or other

substances that cause drowsiness or inattention. 30. Operators are to use extreme caution at all times. Stunt driving and horseplay is strictly prohibited. 31. Failure to follow this policy may result in citation, appropriate disiplinary action, and/or suspension of the

operator’s MUV driving privileges. ADDITIONAL RESPONSIBILITIES

Directors and Supervisors or Designated Person(s): 1. Are accountable for ensuring that all operators within their department understand and comply with the

requirements of this OPERATION OF INSTITUTIONAL MOTORIZED UTILITY VEHICLES (MUVs) policy.

2. Will assure that all operators within their department receive required training and permitting as required by this policy.

3. Will assure that all operators in their department receive and read a copy of this policy.




4. Will train and discuss this policy annually. 5. Will retain the employee’s signed Statement of Understanding for the duration of employment. RMEHS will also

maintain a copy. 6. Will assure that each vehicle owned by their department receives regularly scheduled preventative maintenance

as recommended by the manufacturer. The departments owning MUVs are financially responsible for all maintenance and/or repair costs (labor, parts, and supplies).

7. Will assure that modifying or tampering with the vehicle’s governor does not occur. This is prohibited and is a violation of Federal Law.

Departments that loan their MUVs to other departments are responsible for ensuring that procedures and training are completed for the department/employee accepting the MUV on loan. In addition, any damages sustained to the vehicle will be the responsibility of the department/organization utilizing the vehicle at the time damages were incurred. Any violation of this policy by an individual may result in appropriate disciplinary action, including but not limited to: referral to the Office of Student Conduct (if the violator is a student); referral to Human Resources or Faculty Personnel Services (employee), referral to the organization in which the operator is a member (contractors and visitors); or referral to CMU Police (anyone for violation of traffic laws). Any violation of this policy by a CMU Department, contractor organization, or visitor organization may result in corrective action, including but not limited to: removal of the MUV from the department, suspension of a visitor or contractor organization’s ability to use an MUV on CMU’s campus, or a permanent ban on a contractor or visitor organization’s ability to participate in activities on CMU’s campus.

Central Michigan University reserves the right to make exceptions to, modify or eliminate this policy and or its content. This document supersedes all previous policies, procedures or guidelines relative to this subject.

Central Michigan University Motorized Utility/Low Speed Vehicle

Statement of Understanding/Acknowledgement Form (This form shall be completed by all supervisors/employees/operators prior to

assignment to operating a Motorized Utility Vehicle).

Department:

Employee/Operator Name ______________________________________________________________

(First) (Middle) (Last)

Employee Number: __________________Supervisor:_________________________________________

By signing below, I understand and acknowledge that: (Check all that apply)

□ I have read Central Michigan University's OPERATION OF INSTITUTIONAL MOTORIZED UTILITY VEHICLES (MUV'S) Administrative Policy.

□ I understand the terms and conditions, and agree to abide by and adhere to the OPERATION OF INSTITUTIONAL MOTORIZED UTILITY VEHICLES (MUV'S) Administrative Policy.

□ I have read the Operator's Manual (if available)

□ I have viewed the Safety Training Video (if applicable).

□ I have attended and participated in the operational (hands-on) field training for MUV's (CMU employees/students only)

Date Attended: ___________________

Contractors/Visitors are responsible for training their drivers and agree, by signing this statement, to voluntarily assume all risks associated with MUV use, and agree to release, hold harmless and indemnify Central Michigan University from any liability, claim or expense, including damages, injury or death, arising from, or in connection with the use of an MUV while on CMU property.

Operator Signature Date

Supervisor Signature Date

Approved to Drive: Date:

1 Initials:

Central Michigan University Motorized Utility/Low Speed Vehicle

Statement of Understanding/Acknowledgement Form

Supervisor's Record of Annual Review of MUV Administrative Policy/Training: Write in dates of subsequent reviews in the table below.

Please return completed form to: Environmental Health & Safety - Motor Pool 1303A West Campus Drive

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10 STEPS TO AID YOU IN FOLLOWING CMU’S MOTORIZED UTILITY VEHICLES (MUV) ACCIDENT REPORTING POLICY

1. Do not admit fault or liability. Do not sign any papers.

2. Remain at the scene. Do not move the MUV unless it presents a safety hazard to others. Warn others by placing flares, conesand warning signals as appropriate.

3. Notify the nearest police department about the accident. Notify the police if an ambulance is needed. If you are unable to getto a telephone, ask a passing person to call.

4. Obtain a business card and the report number from officer called to the scene so Risk Management, Environmental Health &Safety can obtain a copy of the police report.

5. Individuals, who are also CMU employees, requiring medical attention due to injuries incurred while in an accident in Mt.Pleasant should use COMP (Central Occupational Medicine Program), 1523 S. Mission - Phone: (989) 773-2339. CMUemployees must report all work-related claims to Workers' Compensation at (989) 774-7177. Facilities Managementemployees' reports need to be filed with Facilities Management Personnel, who, in turn, will file them with Workers'Compensation.

6. Obtain the name, address and phone number of all drivers of other involved vehicles as well as the name and address of anyinjured person(s). Write down the license plate number, make and model of all vehicles involved. Write down the name,address, and phone number of all witnesses.

7. Make notes at the scene of the accident; do a diagram. Do this while details are still fresh in your memory.

8. Protect the MUV and its contents from further loss. Make sure the MUV is locked if applicable; whenever possible, takecontents with you.

9. Reporting Instructions:

a. Facilities Management employees: Call Risk Management, Environmental Health & Safety (989-774-3741) to report youraccident if the Motorized Utility Vehicle cannot be driven, has received major damage or there has been any seriousinjuries. If after hours, call CMU Police (989-774-3081), who will contact the office of Risk Management, EnvironmentalHealth & Safety. If the accident is minor and there are no personal injuries, notify your supervisor or the Service Center(989-774-6547).

b. All others: Call Risk Management, Environmental Health & Safety (989-774-3741) to report your accident if the MUVcannot be driven, has received major damage or there has been any serious injuries. If after hours, call CMU Police (989-774-3081), who will contact the office of Risk Management, Environmental Health & Safety. If the accident is minor and there are no personal injuries, notify your supervisor.

c. In all cases, you must notify your supervisor.

10. Complete a M.U.S.I.C. Motor Vehicle Loss Report and return it to Risk Management, Environmental Health & Safety,Motor Pool 1303A West Campus Drive. This must be done immediately. Forms are available from your supervisor and on the

Risk Management website www.cmich.edu/rm

REMINDERS

1. Anyone driving a University MUV must have his/her driving record checked and approved annually by Risk Management,Environmental Health & Safety prior to operating an MUV.

2. Anyone driving a University MUV must have a valid driver's license in their possession. This driver’s license must beappropriate for the job requirements.

3. All operators of MVUs must have completed training and a signed Statement of Understanding on file with Risk Management,Environmental Health & Safety.

4. All drivers and passengers must wear a properly fastened and adjusted seat belt, if equipped with such.

5. All drivers are prohibited from using hand held cell phones or texting while driving.

6. Make sure you obtain a business card and the report number from the officer called to the scene of the accident so RiskManagement, Environmental Health & Safety can obtain a copy of the police report.

http://www.cmich.edu/rm

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M.U.S.I.C.MOTOR VEHICLE LOSS REPORT

Instructions: Form must be completed in detail. All applicable information is required. Submit report immediately to: CMU Department of Risk Management

00 CMU

Date of Incident: _______________________________, 20__________ Time: _______________AM ______________PM Type of Incident: ________ Accident _________ Theft _________Vandalism _________ Other __________ Location: ______________________________________________________________________________________________________

Street or Highway Number City

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Driver’s Name: __________________________________________________ Faculty Student Staff Volunteer

Home Address: _____________________________ Driver’s Lic. No.: ___________________________

Department: __________________________ Office Phone: ____________ Vehicle Lic. Plate No.: _______________________ Year: _______________ Make: __________________________________ Body Style: ________________________________ Extent of Damages: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Is car drivable: _______________Yes _______________No Vehicle Mileage: ____________________________

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Name of Owner: _________________________________________________ Address: ___________________________________ City: __________________________________________________________ State: _____________________________________ Year: ______ Make: ______________ Body Style: _________ Lic. No.: ___________________________ State: ________ Extent of Damage: ______________________________________________________________________________________________ ______________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________ Company Insured with: ___________________________________________ Address: __________________________________

__________________________________________ Name and Address of Driver: _____________________________________________________________________________________ ______________________________________________________________________________________________________________ Operators Lic. No. and State wherein issued: _________________________________________________________________________

IF MORE THAN TWO CARS WERE INVOLVED IN ACCIDENT, USE ADDITIONAL FORMS

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Description: ___________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

NOTE: All personal injuries must be reported to the claims adjuster immediately.

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1. Name and Address of persons injured in University Vehicle and Nature of Injuries: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Examining Doctor: _______________________________________________ Address: ___________________________________ Hospital: _______________________________________________________ Address: ___________________________________ 2. Name and Address of persons injured in other vehicle and nature of injuries: __________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Examining Doctor: _______________________________________________ Address: ___________________________________ Hospital: _______________________________________________________ Address: ___________________________________ 3. Name and Address of persons injured in other vehicle and nature of injuries: ___________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Examining Doctor: _______________________________________________ Address: __________________________________ Hospital: _______________________________________________________ Address: __________________________________


Name and address of witnesses: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Type of traffic controls or signals: ____________________________________________________________________________________________ Posted speed limit: ____________ Your speed: ____________ Were seat belts used? ______ Yes ______ No ______ By Driver ______ By Passenger Road and Driving: ______ Icy ______ Snow ______ Wet ______ Dry ______ Paved ______ Gravel ______ Fog Were Police Notified? ___________________ Name of Police Agency Notified?

__________________________________________________ Name of Officer: ______________________________________________________________

Badge No.: _______________________________

Traffic Ticket issued to: ________________________________________________________

Violation: _______________________________

Has M.U.S.I.C.’s adjustment service been notified? _____________________________________________________________________________

Indicate on this Diagram What Happened: Draw diagram here if that at left does not suffice.1. Draw heavy lines to show streets2. Name streets3. Draw arrow pointing north4. Show vehicle and pedestrian thus:Vehicles:

Pedestrians:

5. Show angle of collision6. Show number of traffic lanes

Give detailed explanation: _______________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

ADDENUM TO FORM FOR MICHIGAN NO-FAULT INSURANCE BENEFITS

1. Claimant may have the right to personal protection insurance benefits, property protection insurance benefits, and/or residual liabilityinsurance benefits under Michigan no-fault law if in compliance with the regulations and restrictions therein.

2. CMU will pay claims in a timely manner upon approval from the proper authorities.

3. Please contact the Secretary of State for the State of Michigan regarding CMU’s failure to fulfill its responsibilities under the Michiganno-fault law.

Signature of driver: _____________________________________________________ Department: ____________________________________

Date of this report: ___________________________, 20___________


M.U.S.I.C.MOTOR VEHICLE LOSS REPORT

Instructions: Form must be completed in detail. All applicable information is required. Submit report immediately to: CMU Department of Risk Management

00 CMU

Date of Incident: _______________________________, 20__________ Time: _______________AM ______________PM Type of Incident: ________ Accident _________ Theft _________Vandalism _________ Other __________ Location: ______________________________________________________________________________________________________

Street or Highway Number City

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Driver’s Name: __________________________________________________ Faculty Student Staff Volunteer

Home Address: _____________________________ Driver’s Lic. No.: ___________________________

Department: __________________________ Office Phone: ____________ Vehicle Lic. Plate No.: _______________________ Year: _______________ Make: __________________________________ Body Style: ________________________________ Extent of Damages: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Is car drivable: _______________Yes _______________No Vehicle Mileage: ____________________________

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Name of Owner: _________________________________________________ Address: ___________________________________ City: __________________________________________________________ State: _____________________________________ Year: ______ Make: ______________ Body Style: _________ Lic. No.: ___________________________ State: ________ Extent of Damage: ______________________________________________________________________________________________ ______________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________ Company Insured with: ___________________________________________ Address: __________________________________

__________________________________________ Name and Address of Driver: _____________________________________________________________________________________ ______________________________________________________________________________________________________________ Operators Lic. No. and State wherein issued: _________________________________________________________________________

IF MORE THAN TWO CARS WERE INVOLVED IN ACCIDENT, USE ADDITIONAL FORMS

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Description: ___________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

NOTE: All personal injuries must be reported to the claims adjuster immediately.

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1. Name and Address of persons injured in University Vehicle and Nature of Injuries: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Examining Doctor: _______________________________________________ Address: ___________________________________ Hospital: _______________________________________________________ Address: ___________________________________ 2. Name and Address of persons injured in other vehicle and nature of injuries: __________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Examining Doctor: _______________________________________________ Address: ___________________________________ Hospital: _______________________________________________________ Address: ___________________________________ 3. Name and Address of persons injured in other vehicle and nature of injuries: ___________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Examining Doctor: _______________________________________________ Address: __________________________________ Hospital: _______________________________________________________ Address: __________________________________


Name and address of witnesses: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Type of traffic controls or signals: ____________________________________________________________________________________________ Posted speed limit: ____________ Your speed: ____________ Were seat belts used? ______ Yes ______ No ______ By Driver ______ By Passenger Road and Driving: ______ Icy ______ Snow ______ Wet ______ Dry ______ Paved ______ Gravel ______ Fog Were Police Notified? ___________________ Name of Police Agency Notified?

__________________________________________________ Name of Officer: ______________________________________________________________

Badge No.: _______________________________

Traffic Ticket issued to: ________________________________________________________

Violation: _______________________________

Has M.U.S.I.C.’s adjustment service been notified? _____________________________________________________________________________

Indicate on this Diagram What Happened: Draw diagram here if that at left does not suffice.1. Draw heavy lines to show streets2. Name streets3. Draw arrow pointing north4. Show vehicle and pedestrian thus:Vehicles:

Pedestrians:

5. Show angle of collision6. Show number of traffic lanes

Give detailed explanation: _______________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

ADDENUM TO FORM FOR MICHIGAN NO-FAULT INSURANCE BENEFITS

1. Claimant may have the right to personal protection insurance benefits, property protection insurance benefits, and/or residual liabilityinsurance benefits under Michigan no-fault law if in compliance with the regulations and restrictions therein.

2. CMU will pay claims in a timely manner upon approval from the proper authorities.

3. Please contact the Secretary of State for the State of Michigan regarding CMU’s failure to fulfill its responsibilities under the Michiganno-fault law.

Signature of driver: _____________________________________________________ Department: ____________________________________

Date of this report: ___________________________, 20___________