UCCS Automobile Loss Notice

UCCS Automobile Loss Notice [1]

Please fill out this form to report an automobile loss related to the University of Colorado - Colorado Springs campus.

ACCIDENT INFORMATION

Date of Loss *

Month

Day

Year

Accident Location *

Description of Accident *

Authority Contacted & Report Number

UNIVERSITY DEPARTMENT INFORMATION

Department Name *

Department Contact Person *

Department Phone Number *

UNIVERSITY VEHICLE INFORMATION

Year *

Make *

Model *

Color

VIN *

License Plate Number *

Describe Vehicle Damage

UNIVERSITY DRIVER INFORMATION

Driver's Full Name *

Business Phone Number *

Driver's License Number *

Employee Number

OTHER VEHICLE OR PROPERTY INVOLVED

Describe Property

(Make, model, year, plate number, etc.)

Describe Damage

Property Owner's Full Name

Property Owner's Address

Property Owner's Phone Number

INJURED PARTIES

Name, Address, Phone Number, & Injury Description

Reporter's Name *

Date Reported *

Month

Day

Year

Person Reported To *

Additional Comments

Email Address

If you would like a copy of this report, please enter your email address above.

If you are having trouble submitting this report, please email riskmgmt@cu.edu [2] or call 303-860-5682.

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University Risk Management