Online Accident/Incident Report Form

This form is to be completed by UCLA affiliates only (students/staff/faculty)

3rd-party or insurance carriers, please contact Insurance & Risk Management at (310) 794-6948

When an accident happens stop, remain calm, aid the injured and then call the Police 911. If on campus you may call 310-825-1491. Give exact location and advise if medical help is needed. Do not make any statements regarding the assumption of liability. Give out only information required by authorities. Do not sign any statements.

University Vehicle

4 or 6 digit University number found on the rear or the front of the vehicle starting with the number 4. This should correspond to the vehicle you are filing the report for.

Today's Date

Information on the Incident

Date of Incident

Time of Incident

Select approximate time of incident

Was this vehicle stolen?

Incident location

Street name/intersection. Do not abbreviate building name. If you discovered damage to a parked vehicle, then where was the vehicle parked when the damage was discovered. If this vehicle was stolen, where was the last known location.

Describe how incident occurred

Be specific and provide as many details as possible. If you discovered damage to a parked vehicle type "UNKNOWN HOW DAMAGE OCCURRED"

Describe the damage to the UCLA vehicle that you were driving.

Be specific and provide details

Was another vehicle involved in this accident?

License plate number of the UCLA vehicle you were driving

Department name

Which department has ownership of the vehicle you were driving?

Your Supervisor/Reservation Authorizer/Transportation Director contact information

Contact Name/Phone/Email

Information on UCLA Driver or Person Discovering Damage on the Vehicle

Driver First Name

Driver Last Name

Driver University Affiliation

Select option from drop down arrow

Driver 9 Digit University Identification Number (UID)

Driver Contact Number

Phone

Driver Email

Other vehicle driver information

DO NOT INCLUDE DRIVER LICENSE NUMBER

If the information is unknown, type "UNKNOWN" or "N/A"

Additional Information

Are there any witnesses?

Are there any injuries?

Select option from the drop down arrow

Was a police report filed?

Accident Conditions

Do you believe there is any picture or video evidence that captured the accident?

What was the road condition like when the accident took place?

You may select more than one option. You may also write in your answer.

How was the traffic condition when the accident took place?

You may select more than one option. You may also type in your answer.

Were there any traffic controls at the accident site?

You may select more than one option. You may also type in your answer.

Information on Person Filing the Incident Report

Who Are You In Relation to this Incident Report?

Select option from the drop down arrow

Photos

Please take and attach to the report a minimum of 4 photos and a maximum of 10 photos using the criteria below:

(1) photo of front or back of vehicle displaying license plate number and 4 or 6 digit University vehicle number.
(1) photo of damage to University vehicle from 7 to 8 feet away.
(1) photo of damage to University vehicle from 2 to 3 feet away.
(1) photo of the street/intersection/location where the accident took place or the damage to the vehicle was discovered.
If additional vehicles were involved, photograph damage to the other vehicle(s) as well as any insurance documents provided by the other driver(s).
If your University vehicle did not sustain any damage, please take the same photos listed above centering on the point of impact.

DO NOT ATTACH ANY PHOTOGRAPHS OF DRIVER LICENSE

Photos

Drop your files here

E-Signature

Ensure all required fields (*) have been completed and photographs have been attached. Incomplete reports will not be submitted.

This checkbox serves as my signature and indicates that the information contained above is true to the best of my knowledge.

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