General Liability Claim Reporting Form

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GENERAL LIABILITY CLAIM REPORTING FORM
Date of Loss___________ Time _______ ORM Location Code________________________________
Names of All Parties Involved __________________________________________________________
Who was Notified? 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:
FARA
Submit by Email
Print This Form

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