Auto Physical Damage Claim Report

Any state vehicle or vehicle being used in the course and scope of employment must be reported immediately to the approprioate police agency. Accidents must also be called into the Netclaim Network at 1-877-656-7475 within 48 hours. For questions contact Vance Silcott phone (706-425-3083) or email vsilcott@uga.edu.


Person Reporting Claim: *

Department Reporting Claim: *

Claimant: *

Claimant Phone Number: *

Claimant Email:

Net Claim Report:

Net Claim Number:

Subrogation Name:
Subrogation Claim No:

Supervisor Name:

Supervisor Department:
Supervisor Phone:

Driver Name:

Vehicle Owner:

Vehicle Identification Number (VIN):

Vehicle Year:

UGA Vehicle Number:

Vehicle Model:

Vehicle Tag:

Rental Vehicle: *

Rental Car Company:

Injury/Death: *

Name:

Additional Injured Parties Name:

Medical Treatment Received:

Details:


Date of Loss: *

Time of Loss:

Police Department:

Police Report Number:

Description of Loss:


Street:

City:

State:

Zip:


 


University of Georgia