Building Property Damage-Loss

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					                                  Bedford County Department of Fire & Rescue
                                  1305 Falling Creek Road Bedford, VA 24523
                                  Phone: 540.587.0700  Fax: 540.586.2176

                               Building/Personal Property Damage/Loss
                                             * * * PLEASE PRINT * * *

                                            GENERAL INFORMATION
Department Name:                                              Contact Person:
Property Address:                                             Contact Phone Number(s):
Station #                                                     Weather Conditions:
   Date Of Loss          Day Of Week        Date Reported     Equipment Involved:


Location Of Incident:                                         Have You Attached An Estimate Of Damage/Loss?
                                                              Amount Of Estimate: $
Please List Names Of Any Witnesses:


Was there any Personal Injury to a Fire/Rescue Member? Yes / No
If "YES" complete this form and complete a First Notice Of Claim Form

Describe What Happened?




Why Did It Happen?




What Should Be Or Has Been Done To Prevent A Reoccurance:




What Immediate Action Has Been Taken?




Signature Of Person Making Report:                                                  Date Signed:
Printed Name Of Person Making Report:
                           * * * BEDFORD COUNTY FIRE & RESCUE SAFETY COMMITTEE * * *
Recommendations Of The Bedford County Fire & Rescue Safety Committee:


Should Any Actions / Corrective Actions Be Taken:


Signature Of Safety Officer:                                                        Date Reviewed:
            *** Please Complete And Return Form To Bedford County Fire & Rescue Office Within 24 hours ***

                                                                                             Created: March 8, 2007
                                                                                             BCFR/Forms/Insurance
                                Bedford County Department of Fire & Rescue
                                1305 Falling Creek Road Bedford, VA 24523
                                Phone: 540.587.0700  Fax: 540.586.2176

                                      Auto Accident / Auto Damage
                                             * * * PLEASE PRINT * * *

                                            GENERAL INFORMATION
Department Name:                                              Contact Person:
Property Address:                                             Contact Phone Number(s):
Station #                                                     Weather Conditions:
   Date Of Loss          Day Of Week        Date Reported                        Vehicle Information:
                                                              Make / Model / Year:
Location Of Incident:                                         VIN #
                                                              Have You Attached An Estimate Of Damage/Loss?
                                                              Amount Of Estimate: $
Please List The Name Of Person Driving The Vehicle:
Please List Names Of Members Riding In Vehicle:


Was there any Personal Injury to a Fire/Rescue Member? Yes / No
If "YES" complete this form and complete a First Notice Of Claim Form

Please List Names Of Any Witnesses:


Describe What Happened?




Why Did It Happen?




What Should Be Or Has Been Done To Prevent A Reoccurance:




What Immediate Action Has Been Taken?


Signature Of Person Making Report:                                                   Date Signed:
Printed Name Of Person Making Report:
                           * * * BEDFORD COUNTY FIRE & RESCUE SAFETY COMMITTEE * * *
Recommendations Of The Bedford County Fire & Rescue Safety Committee:


Should Any Actions / Corrective Actions Be Taken:


Signature Of Safety Officer:                                                         Date Reviewed:
            *** Please Complete And Return Form To Bedford County Fire & Rescue Office Within 24 hours ***

                                                                            Created: March 8, 2007 * Revised: April 27, 2007
                                                                                                     BCFR/Forms/Insurance