Auto Accident Report
| Employee's Information | |
| Employee Name: | |
| Stanford I.D.: | |
| Driver's License No: | |
| Address: | |
| Residence Phone: | |
| Work Phone: | |
| Where can we contact you? | |
| When? | |
| Accident Information | |
| Date/Time of Accident: | |
| Location of Accident: (incl. City and State) | |
| Police Dept. to whom reported: | |
| Description of Accident or Loss: Include all information of Other Party involved | |
| SU Vehicle No. | |
| SU Year, Make, Model | |
| SU Vehicle Identification No. | |
| SU License Plate No. | |
| APPLICABLE IN CALIFORNIA -- For your protection, California law requires the following appear on this form: It is unlawful to: (A) Present or cause to be presented any false or fraudulent claim for the payment of a loss under a contract of insurance, (B) Prepare, make or subscribe any writing with intent to present or use the same, or allow it to be presented or used in support of any such claim. Every person who violates any provision of this section is punishable by imprisonment in the state prison not exceeding three years, or by fine not exceeding one thousand dollars or by both. | Reported by: | Reported to: |
Risk Management, Mail Code: 6207
(01/03)