Whitfield, Dora CCITY CLAIM #:
% RISK MANAGEMENT INCIDENT REPORT L: D
(Other than Workers' Compensation) NOV 2 6 2002
PART I: BASIC INFORMATION =:? `,"1E=fVi
DATE OF INCIDENT: 1 r ! gLOd- TIME OF INCIDENT: A.M. / j;6V P.M.
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LOCATION OF INCIDENT:
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POLICE REPORT NUMBER: Oa- 31 U-& COST CENTER. CODE:
DESCRIPTION OF INCIDENT: (Use additional paper, if necessary): a+,r,r. az
NAME OF DRIVER/OPERATOR: JOB TITLE:
kECE?IVED
CONTACT PERSON: PHONE NO:
A. CITY VEHICLE INVOLVEMENT
CITY VEHICLE NO: YEAR, MAKE, MODEL: RISK MANAGEMENT
DESCRIBE TYPE OF DAMAGE (DENT, SCRATCH, PAINT TRANSFER, ETC.) AND PORTION OF
VEHICLE AFFECTED:
REPAIR ESTIMATE: (ATTACH RECEIPTS OR ESTIMATES IF VALUE KNOWN)
B. CITY PROPERTY INVOLVEMENT
DESCRIBE TYPE OF DAMAGE (DENT, SCRATCH, PAINT TRANSFER, THEFT, ETC.) AND
PORTION OF PROPERTY AFFECTED:
1
PART II: CITY INFORMATION
DESCRIPTION OF PROPERTY (INCLUDE SERIAL #/ADDRESS OR OTHER IDENTIFIER):
REPAIR ESTIMATE: q 00 (ATTACH RECEIPTS OR ESTIMATES IF VALUE KNOWN
PART III: CITIZEN INFORMATION
OWNER
CONTACT PERSON: (If different than property owner)
ADDRESS :
HOME PHONE:
WHERE CAN CITIZEN BE CONTACTED?
WHEN?
NAME OF
A. CITIZEN INVOLVEMENT/AUTO:
ADDRESS: PHONE #:
DESCRIBE PROPERTY (Make, Model, Year):
IS CAR INSURED? YES NO POLICY NO.:
INSURANCE COMPANY NAME:
INSURANCE COMPANY ADDRESS:
DESCRIBE TYPE OF DAMAGE (DENT, SCRATCH, PAINT TRANSFER, ETC.) AND PORTION OF
VEHICLE AFFECTED:
WHERE CAN AUTO BE SEEN?
B. CITIZEN INVOLVEMENT/OTHER THAN AUTO
NAME OF OWNER: A "
ADDRESS: PHONE #:
DESCRIBE PROPERTY:
IS PROPERTY INSURED? YES NO POLICY NO: _
INSURANCE COMPANY NAME:
-
INSURANCE COMPANY ADDRESS: Ris r ENT
WORK PHONE:
2
DESCRIBE DAMAGE:
REPAIR ESTIMATE: WHERE CAN PROPERTY BE SEEN?.
PART IV: INVESTIGATION AND SIGNATURE
WITNESS STATEMENTS: Include all passengers. Please provide names, addresses and telephone
numbers of witnesses and their statements. (Use additional paper, if necessary)
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WAS THIS INCIDENT REPORTED TO RISK MANAGEMENT? _ YES NO
IF YES, WHEN? I c?, BY WHOM? Ov. s QaS446t?
VIA: TELEPHONE _X' _MEMO E-MAIL OTHER
PHOTOS TAKEN? BY WHOM? 0. arj Z14 q
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WAS A CITATION ISSUED? TO WHOM?
PLEASE ATTACH A DIAGRAM TO THIS REPORT IF A POLICE REPORT WAS NOT MADE.
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PREPAF.ER'S SIGNATURE: _ DATE: ///.)0/0')
_ I have read and agree with the contents of this report.
I have read and disagree with the contents of this report. (Please provide a description of the areas of
disagreement, using a separate piece of paper.)
EMPLOYEE SIGNATURE: ? /a DATE:
DEPT. REVIEWER SIGNATURE: DATE:
9830-0009
Share Drive/Risk Management Incident Report
3/99
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