Insurance Safety Maintenance Repair Request Form

I. Policy

A. A three-part maintenance Repair/Request Form will be required for all vehicle repairs, servicing, preventive maintenance, and all other general work performed on all company vehicles. The purpose of this form is to provide a document to track vehicle repair, monitor vehicle operating costs, educational instructions to the operator/driver, advise management of abuse of vehicles, and to monitor parts inventory.

B. There shall be three pages to the Maintenance Repair/Request Form, each page should be color coded with the following distribution:

1. Page-1, Operator/Driver, sent to the person who initiated the request, so they know the repairs have been completed, and the vehicle is safe to operate. (You may prefer to black out actual repair costs, on the Operator/Driver copy.

2. Page-2, Management and Accounting, sent to management for review and the routed to accounting for fiscal control.

3. Page-3, Maintenance Department, (Hard Copy) to be filed in the individual vehicle maintenance file.
a. Preventive Maintenance Checklist should be attached to the (Hard Copy).
b. Work Orders from outside repair facilities should be attached to the (Hard Copy), with copies attached to Page-2.
c. The maintenance departments Individual Vehicle File, is the main docu-ment for the maintenance history on the vehicle.

II. Procedure

A. The Operator/Driver will initiate the Repair/Request Form after experiencing a vehicle failure or problem. The Operator/Driver will fill out the following information:
1. Vehicle 1.0.
2. Date of problem
3. Location
4. Mileage
5. Vehicle license number
6. Was the vehicle in service or parked at the time
7. Describe the actual problem or symptoms the vehicle experienced, in your own words.

B. The chief mechanic will be responsible for completing the second part of the form after the crew has reported a problem. It shall be his/her responsibility to fully document:
1. Date repairs were completed.
2. Time vehicle came in for repairs and maintenance.
3. Time repairs were completed.
4. Service performed/Problem found.
5. Parts and expandable supplies used.
6. Costs of parts and supplies.
7. List total hours required to complete the work.
8. Outside repairs.
9. Comments to the crew by the mechanic who completed the repairs.
10. Signed by the mechanic who completed the repairs.
11. Comments to management by the Chief Mechanic.
12. Fill in appropriate information as requested by management.

C. Each form will be consecutively numbered and have the company name at the top.

D. The form will be filled out in black permanent ink.

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