MOTOR VEHICLE LOSS REPORT FORM
Please complete the following information:
Report date and time:
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Month
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Day
Year
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10
11
12
:
Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date and time when incident occurred:
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Month
-
Day
Year
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1
2
3
4
5
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8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Driver's Name:
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Mr/Ms/Mrs
First Name
Middle Name
Last Name
Driver's Contact Phone Number:
*
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Area Code
Phone Number
Driver's Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver's Vehicle Information:
*
Driver's License Number
Vehicle License Plate Number
Vehicle Make
Vehicle Model
Vehicle Year
Did you file a police report?
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Yes
NO
If you filed a police report,
email a copy of the report to riskmgmt@oakland@oakland.edu
Incident Location (Please provide specific details):
*
Details of incident
*
Additional Comments/Questions:
*
I certify that the above information is true and correct.
Report Now!
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