Updated November 18, 2013
City of Portage
Accident Investigation Forms
(Liability and Property Claims)
Type of Claim:
Bodily Injury
Property Damage
Property Loss
Date of Accident: Time of Accident: AM/PM
Date Accident Reported: To Whom Reported:
Location (address) of Accident:
Owner of Premises Where Accident Occurred:
Occupant of Premises Where Accident Occurred:
Describe fully how accident occurred:
Witnesses:
Name
Address
Phone Number
(1)
(2)
(3)
Injured Person:
Name: Address:
Nature of Injury:
Attended by:
Property Damage:
Name of Owner: Address:
Nature of Damage:
Estimated Cost of Repair:
Comments:
Signature of Person Submitting Report:
Date:
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