Incident Report General Liability Property Automobile  
Submit an Incident Form
What to Report:
A reportable incident is any event which results in a loss, or may have caused a loss which under similar or slightly different conditions could result in serious injury or significant damage to personnel, assets, earnings, or general public.
  Contact Info 
  Name:
  Email:
  Phone:
  Incident 
  Date of Incident:
  Time of Incident:
  Place of Incident:
  (please include address and describe area)
  Type of Injury:
  (i.e fell, struck, pushed)
  Weather/Surface Conditions:
  First Aid YES  NO 
  Medical Care:
 
(other than first aid)
  Dispostion:
 
Fatality (if yes, Ambulanced to:)
Personal Auto (if yes, to:)
Continued on premise activity
Refused Treatment
  Describe Accident:
 
(i.e. walking, going down stairs, in vehicle, fighting, playing)
  Witnesses 
  1
  Name:
  Address:
  City:
  State:
  Zip
  Phone Number:
  2
  Name:
  Address:
  City:
  State:
  Zip
  Phone Number:
  Injured Parties 
  1
  Injured Pary Type:
 
(i.e. customer,vendor, passerby)
  Name:
  Address:
  City:
  State:
  Zip
  Phone Number:
  2
  Injured Pary Type:
 
(i.e. customer,vendor, passerby)
  Name:
  Address:
  City:
  State:
  Zip
  Phone Number:
  Property Damages 
  Property Damage:
 
(describe the type of property and damage)
  Fire Dept Involved:
  Fire Dept Report #:
  Police Dept Involved:
  Police Dept Report #:
  Recommendations for Correct Action: