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 MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201620172018201920202021 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 Name, Address, Phone Number, & Injury Description Reporter's Name * Date Reported * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 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 email@example.com or call 303-860-5682. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.