Auto Accident Report

Department Information

Reporting Type

Department Name

Person to Contact

Phone

State Vehicle Driver's Name

Date of Accident

Time of Accident

Exact Location of Accident

Describe how accident happened

Seat Belt in Use

State Vehicle Information

Information about the primary vehicle involved in accident.

State Vehicle Driver's Address

City

State

Zip Code

Home Phone

Work Phone

Drivers License #

Vehicle Owner's Name

Vehicle Owner's Address

Vehicle Year

Vehicle Make

Vehicle Model

License Plate #

V.I.N. #

Where is vehicle presently located?

Describe Damage

Other Vehicle Information

Information about other vehicle involved in accident.

Other Vehicle Drivers Name

Other Vehicle Driver's Address

Other Driver's Home Phone

Other Driver's Work Phone

Other Vehicle Owner's Name

Other Vehicle's Owner Address

Other Vehicle Year

Other Vehicle Make

Other Vehicle Model

Other Vehicle Body Type

Other Vehicle License Plate #

Where is other vehicle presently located?

Other Vehicle Insurance Company

Other Vehicle Insurance Policy #

Describe Damage to Other Vehicle

Investigation Information

Information about law enforcement investigation.

Police Investigated?

Type of Report

Report #

Name of Driver's Immediate Supervisor

Driver's Immediate Supervisor Phone #

Report Attachment

Please upload the Police Report and/or any other relevant documents.

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.

Send me a copy of my responses

Report Abuse