Incident Report for ALL Claims
Date Report Completed:
Injured Party’s Name:
Address of Injured Party:
Phone Number of Injured Party:
Address/Location of Incident:
Date of Incident:
Time of Incident:
Description of vehicle, equipment, or property involved:
Nature of damage or loss:
Estimated cost for replacement/repair:
(Attach copy of estimate for replacement/repair)
Describe in detail what happened:
Name, address and phone number of witnesses:
Please attach diagram or drawings when feasible.
*Print completed form, sign and return form to supervisor/department head.
*Supervisor/Department Head – send completed report to Debbie Chow, Insurance
Specialist, Administrative Services Department.