General Liability Claims/Incident Report Form

General Liability Claims/Incident Report Form

Reporting Type*

Select

Claim Reporting Acknowledgement*

I acknowledge that I am submitting a claim report. I or someone related to the described incident wishes to file a claim in order to seek a response concerning liability of the University in relation to this incident. I acknowledge that this claim report will be reviewed by LSU Risk Management, that I will be contacted once LSUORM begins the investigation into this incident, and that I will assist in the investigation of this incident.

Incident Report Acknowledgement*

I acknowledge that I am submitting an incident report only. I do not wish to file a claim in relation to the described incident. I acknowledge that this incident report will be reviewed by Risk Management and I will be contacted only if LSUORM needs more information.

Campus

LSU A&M

Date of Incident*

Time

Name of Claimant*

Address of Claimant*

City*

State*

Select or enter value

Zip Code*

Phone Number- Home

Phone Number- Cell

Best Email for Claimant*

Who was notified?

Police

Agency

Others

Describe Incident and Police/Agency/Etc Response:*

Attach additional information, official reports & photos at bottom of form

Injury Information

Type and extent of Injury known

Name of Injured Party

Phone

Personal Property Damage

Description of Property and Damage

(Age/Make/Model/Cost of Repairs)

Name of Owner

Address:

LSU Residence Hall (if applicable):

City:

State:

Select or enter value

Zip Code:

Witnesses:

Name of Witness 1:

Phone Number of Witness 1:

Name of Witness 2:

Phone Number of Witness 2:

Reported By:*

Date Reported:

File Attachments

(Please attach additional information, official reports, & photos)

Drag and drop files here or

Data Authorization*

I authorize that all information provided on this form, including any and all personal, financial and academic data may be shared with the LSU Risk Management and university insurance carriers and vendors. This data will be securely retained indefinitely. To learn more about privacy at LSU, please see the LSU Privacy Statement.

Send me a copy of my responses

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