1. U.T. Institution _____________________________________ Report No. ___________
2. Date of incident causing possible claim _____________________ Time ___________
3. Name and address of possible claimants:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
4. Names and addresses of all known witnesses:
__________________________________________________________________________
__________________________________________________________________________
5. If university motor vehicle involved, attach a copy of Accord Form No. 2 prepared for insurance company and list:
a. Make and number of vehicle _________________________________________
b.
Name of driver ____________________________________________________
c.
Location of incident ________________________________________________
d.
Extent of personal injuries to driver and passengers
____________________
_____________________________________________________________________
e.
Extent of property damage ___________________________________________
f. Was
traffic citation issued? ___ yes ___ no If yes, to whom and for what
violation?
_____________________________________________________________________
g.
Insurance carrier has been notified: ___ yes ___ no
6. Describe incident: Indicate equipment involved and its condition; identify premises (real or personal property) condition or use involved. For example, if incident involved a "slip and fall," describe the condition of the floor. Attach additional material as needed.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
7. Has possible claimant or representative indicated intention to proceed
with legal action? ___ yes ___ no
If yes, explain briefly:
___________________________________________________________________________
___________________________________________________________________________
8. Name of attorney, if known ________________________________________________
Reported by ___________________________________________ Date/Time __________________
Department of Institution _______________________________________________________
Distribution: Original to Vice Chancellor and General Counsel, The University of Texas System; Copy to Executive Vice Chancellor for Business Affairs.