STATE OF GEORGIA

General Liability Accident Report Form

 

If you see this don't fill out this input box.

Accident Information - General Liability

State Agency Involved: University of Georgia

Date and time of Incident*

Incident Location

City and County

Description of the accident*

Police authorities contacted

If yes, Accident Report Number

Claimant Information

Name & Address of the Claimant

Telephone No

Injury Information

Brief description of the claimant's injury

Fatality

Yes

No

What initial treatment was given?

Was hospital treatment needed?

Which hospital?

Witness Information

Were there any witnesses?

Yes

No

If so, their name, address & phone no

Property Damage to Others Information

Claimant's property involved

Where is the property located now?

Damage to Claimant's property

Repair/replacement estimate

Contact Information of Person completing form

Your Name

Phone Number

Email Address (enter email address to receive copy of report submitted)

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