General Liability Claims/Incident Report Form

Reporting Type

Campus

Date of Incident

Time

Name of Claimant

Address of Claimant

City

State

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:

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:

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

Drop your files here

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.

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