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Police? ____ Agency? ______ Others? ___________________________________ Description of Incident and Action Taken: ___________________________________________________________________________________ ___________________________________________________________________________________ (Attach additional information, official reports & photos [see next page]) Injury Information: Type and extent of injury known: _________________________________________________________ Name of injured Party: ___________________________________Phone _________________________ Address: _________________________________City/State ___________________________________ Name/Address of Attorney: ______________________________________________________________ Damage to Others’ Property: Description of Property & Damage (Age/Make/Model/Cost of Repairs) ____________________________ ____________________________________________________________________________________ (Attach additional Information if available) Name of Owner: _____________________________________Phone ___________________________ Address: __________________________________City/State __________________________________ Witnesses: Name: _____________________________________________Phone ___________________________ Address: __________________________________City/State __________________________________ Name: _____________________________________________Phone ___________________________ Address: __________________________________City/State __________________________________ Reported by: ___________________________________Date: ________________________________ Contact Person: _________________________________Phone ________________________________ Use this form to report incidents affecting members of the general public or others while on State property which you believe could reasonably result in a claim against the State. Do not use for auto accidents or Workers Compensation claims. Send completed report to: Office of Risk Management P. O. Box 94095 Baton Rouge, LA 70804-9095 SUGGESTIONS FOR REPORTING GENERAL LIABILITY CLAIM Were photographs taken? Please include originals (photocopies are seldom adequate). Was a police report / incident report created? Please include copy(ies). The more detail you can supply, the better. For example, when reporting slip/trip and fall incidents: Was the claimant wearing glasses? What type of shoes? What kind of soles? Does claimant have any handicaps/disabilities? Was he/she on any medications? What kind of surface was claimant walking on? What was the lighting condition? Was surface wet or dry? Any debris present? Any defects? Surface irregularities? For stolen items, Were they secure? What kind of lock? Who has keys or access? Supply brand name, original cost, date of purchase. 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