Form Egs-Rm - Citizen Vehicle Report Form
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1Risk Management | EGS
E-mail:
risk.management@oregon.gov
PO Box 12009,
Website:
State of Oregon: Risk Management
Salem, OR 97309-0009
Form Web address:
503-373-7475
503-373-7337 fax
CITIZEN VEHICLE REPORT FORM
Fill out each line as completely as possible.
Date of Incident:
State License Plate Number:
Location of Incident:
Time of Incident:
City/State:
Street(s):
Direction of travel:
Describe Incident. Please be specific:
Description of Vehicle: Make:
Model:
Color:
Description of Driver:
Description of Passengers:
Would you like a response from Risk Management? Yes
No
If your answer is YES, please complete the information below. If you do not provide contact information or it is
incomplete, you will not receive a response from us.
Name:
Address:
City:
State:
Zip:
Daytime Phone (
W
H):
Other (
W
H):
Email Address:
PRINT
SUBMIT
Official Use Only
Risk Management claim #: _ _
_Date Received
Agency Name:
Agency Number_
Assigned Driver:
Actual Driver:
Page 1 of 1
Revised 3/16/2016
Form No. EGS-RM Citizen Report Notification Intake Form
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Parent category: Legal