AUTO COLLISION INFORMATION FORM
TEXAS TECH UNIVERSITY SYSTEM
If you have a collision, use this form to record the facts about the collision, including names and address of all parties involved, and
any witnesses to the collision. Give the completed form to your Department head. The Department head will send the form to
Office of Risk Management PO Box 42003 (MS 2003) Lubbock, Texas 79409
Date of collision and time AM PM Location of Collision (Include City & State)
Description of Collision (use reverse side if necessary)
Authority Contacted and Report # Any violations/citations as a result of the collision (describe)
PROPERTY DAMAGED (NOT YOUR VEHICLE)
Describe Property Insurance Company
(If auto, year, make,
model, plate #)
Owner's Residence Phone
Name & (A/C, No. Ext):
Address Business Phone
(A/C, No. Ext):
Other Driver's Residence Phone
Name & Address (A/C, No. Ext):
(Check if
Business Phone
same as owner) (A/C, No. Ext):
Driver's License Number Describe Damage Where can damage be seen?
Insurance Company Name Policy Number Agent's Name and Number
INJURED PARTIES
Name & Address
Phone (A/C, No)
Age
Describe
Injury
Injured was: Pedestrian In your car In other car
Injured was: Pedestrian In your car In other car
WITNESSES OR PASSENGERS
Name & Address Phone (A/C, No.)
Ins Veh
Oth Veh Statement Attached?
YOUR INSURED VEHICLE
Year Make Model VIN License Number
Department Name Department Phone
Supervisor to whom you reported: (A/C, No)
Department Head Name
Driver's Name Residence Phone
& Address (A/C, No)
Business Phone
(A/C, No. Ext):
Relation to Insured Date of Birth Driver's License # State Purpose Used with Permission
(Employee, family, etc.) of Use Yes No
Describe
Where can When can Vehicle
Damage Vehicle be seen? be seen?
In addition to this form please provide a copy of the police report and OP 80.08 attachments B & C. In the event of collision
always contact the appropriate law enforcement agency and ask that they prepare an accident report.
Attachment A
OP 80.08
6/17/15
