Auto Accident Report

Auto Accident Report

Department Information

Reporting Type*

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Department Name*

Person to Contact*

Email*

Phone*

State Vehicle Driver's Name*

Date of Accident*

Time of Accident

Exact Location of Accident*

Describe how accident happened*

Seat Belt in Use

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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?

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Type of Report

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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.

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.

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