Vehicle Accident Report | Lawrence University

If you've had an accident in a Lawrence vehicle, please fill out this form. We'll contact you for more details.

If you prefer to fill in a PDF form instead and send it via campus mail to Kay Guilette @ Brokaw Hall, you can do so by going to this PDF Vehicle Accident Report.pdf

LU Driver Information

First Name

Last Name

Middle Initial

Home Address

State

Zip

Home Phone

Cell Phone

Work Phone

Date of Birth

Year

Month

Day

Driver Injured

Yes

Wearing Seatbelt

Yes

Passengers in Vehicle(Excluding the driver)

Number of Injured Passengers

Was everyone wearing their seatbelt?

Yes

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