University of Georgia - Claims Report

General Liability Claim Report

Notify the University of Georgia Police; 706-542-2200 or local law enforcement authorities to report all incidents resulting in an injury or property damage. 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:

UGA or Other Responding PD Report:

UGA or Other Responding PD Incident Number:

Supervisor Name:
Supervisor department:	Supervisor Phone:

Property/Vehicle Owner Name:

Property/Vehicle Owner Address:

Property/Vehicle Owner Phone Number:

Property/Vehicle Owner Email:

Injured/Death: *

Name:

Additional Names:

Medical Treatment Received:

Details:

Witness Name: Witness Phone Number:

Date of Loss: *

Time of Loss:

Police Department:

Police Report Number:

Description of Loss:

Building

Street

City

State

Zip

University of Georgia