ࡱ> UWT bjbj > &&e&e&e&y&y&y&y&&Ty&l1n&&&&&)))0000000$2|51e&)n)@)))1&&&&o&1))))&8&e&&0))0))6/M&0&pXV0Cy&)w00<10l1086)868086e&0())))))))11))))l1))))86))))))))) $: 51 Office of Risk Management 306 Whitehurst Stillwater, OK 74078-1022 Phone: 405-744-5981 STANDARD LIABILITY INCIDENT REPORT AGENCY NAME: 51 - CODE: PHONE: TYPE OF EMPLOYMENT (please circle one): Full-Time Temporary Volunteer Contract DRIVER or EMPLOYEE:_____________________________________ JOB TITLE:________________________________ DEPT:_____________________________ ADDRESS:_________________________________ PHONE:______________ SPECIFIC DUTY BEING PERFORMED:____________________________________________________________________  VEHICLE INFORMATION: OWNED BY: State___ Other___ MAKE:_____________________________________________ YEAR:_________ BODY TYPE:____________________ VEHICLE TAG #:_____________________ OSU VEHICLE #:________________ AMOUNT DAMAGE:______________________ WHERE DAMAGED:___________________________________________  CLAIMANTS NAME:______________________________________________________ PHONE:___________________ ADDRESS:_______________________________________ CITY:_____________________ STATE:____ ZIP:_________ WAS CLAIMANT OR PASSENGER INJURED?______ DESCRIBE:_______________________________________________ ___________________________________________________________________________________________________ NAME OF DOCTOR OR HOSPITAL:_______________________________________________________________________ CLAIMANTS VEHICLE:________________________________________________________________________________ Make Year Body Type Amount of Damage WHERE DAMAGED:___________________________________________________________________________________ CLAIM FORM REQUESTED? Yes___ No___  INCIDENT DATE:______________ TIME:_____________ LOCATION:________________________________________ ___________________________________________________________________________________________________ Give: City - Street - Highway - County DESCRIBE INCIDENT:_________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ WAS EMPLOYEE AWARE OF INCIDENT? Yes___ No___  Send original to OSU Risk, Plant, & Property Management The information contained in this document is protected by the attorney/client and/or the attorney work privilege. The information is strictly confidential and is intended solely for the use of the recipient. You are hereby notified that reading and/or distributing this and/or the accompanying transmission is prohibited.  REMARKS:__________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ _____________________________________________________________________________________ ___________________________________________________________________________________________________  DIAGRAM OF ACCIDENT: CAR #1- EMPLOYEE CAR #2- CLAIMANT  WITNESSES: Name Address Phone ______________________________ ______________________________________ ________________ ______________________________ ______________________________________ ________________ ______________________________ ______________________________________ ________________  AUTHORITIES REPORTED TO:_______________________________ NAME:_________________________________ WERE THERE ANY CITATIONS? 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