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.