Incident Report



Incident Report
Today's Date: Oct 20 2017
Member:
Contact Email Address:
Address:  City:  State:  Zip:
Contact Person: Phone:
Member's Vehicle (if applicable): Vin No:
Driver: Home Phone:
 
Date of Loss* (required):     Time of Loss:
Location of Loss:
Describe Incident:
Follow Up Action Taken:
Name & Phone Number of Member with the Most Knowledge of Facts of Incident:
 
Claimant's Name:
Address:
 City:  State:  Zip:
Home Phone: Work/Cell Phone:
Injury: yes no Property Damage: yes no
Was injured person moved from scene: yes no If so, how?
Was accident investigated by authorities: yes no If so, who?
Was citation given? yes no
Claimant Given Claim for Damage Form? yes no
 
Addtional Comments:
Witness (1) Name:
Address:
 City:  State:  Zip:
Home Phone: Work/Cell Phone:
Witness (2) Name:
Address:
 City:  State:  Zip:
Home Phone: Work/Cell Phone:
Witness (3) Name:
Address:
 City:  State:  Zip:
Home Phone: Work/Cell Phone:
 
**ADDITIONAL INFORMATION REQUIRED FOR AUTOMOBILE CLAIMS ONLY**
Claimant Vehicle Information
License Plate # Driver License #
Type Auto:  Year:  Make:  Model:
Driver Owner
Name: Name:
Address: Address:
City: City:
State:    Zip: State:    Zip:
Phone#: Phone#:
Passenger (1) Name:
Address:
 City:  State:  Zip:
Passenger (2) Name:
Address:
 City:  State:  Zip:


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