Incident Report
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3INCIDENT REPORT
Exhibit F
Updated 10/16/2001
Page 1 of 3
Risk Management Use Only:
City Incident #
Liability:
Property Loss/Damage:
Auto Loss/Damage:
SECTION I
(Complete in full)
1.
Incident Information:
Reporting Date:
Date of Incident:
Location of Incident:
City:
State:
Zip:
Type of Loss: (Auto, Property, Injury-Fire, Wind, Etc.)
Describe what happened:
City Employee Involved in Incident:
Contact Person for Additional Information:
Witness/Passenger Name(s):
Address:
Phone #:
Was a Police Report Filed?
Yes
No
Report #
Where Filed?
SECTION II
(Complete A, B or C)
A. For Auto/Motorized Equipment Loss/Damage Municipal Vehicle Information
Plate:
VIN:
Vehicle #
Year:
Make:
Model:
Driver’s Name:
Department:
Describe Damage:
Where can Vehicle be Seen?
C:\dexform\good_results\xml\nolinks\221840.xml
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Parent category: Business