CITI
ZEN INFORMATION
Name of Injured Party or Owner of Property Damaged __________________________________________________________________________________________
If a Minor, List Parent/Guardian ____________________________________________________ Age _____________ Date of Birth ____________________________
Home Address ______________________________________________________________________ City_________________________ State ___________________
Phone __________________________________________ Marital Status if Known ______ Married ______ Not Married
INJURY/DAMAGE
Date of Injury/Damage ____________________ Time _____________ Address Where Public Injury or Damaged Occurred _____________________________
__________________________________________ Specific Location at Address _____________________________________________________________________
Reported by Whom? _____________________________________________________________________________________________________________________
Describe Incident & Resulting Injury or Damage _______________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
MEDICAL CARE/CONTACTS
What First Aid/Care Was Given? ___________________________________________________________________________________________________________
By Whom? _________________________________________________________ Was Ambulance Called? _______________ By Whom? ______________________
Did Injured Party Seek Medical Attention? ________________________________ Where? ____________________________________________________________
If Follow Up Contact Was Made, By Whom? ________________________________________ Comments ________________________________________________
______________________________________________________________________________________________________________________________________
WITNESSES
Name, Address, Phone # _________________________________________________________________________________________________________________
Name, Address, Phone # ___________________________________________________________________________________________________________
______
PREPA
RED BY
Department _____________________________________________________________ Date Prepared _________________________________________________
Employee Name _________________________________________________________ Supervisor _____________________________________________________
E-mail this completed form along with all photographs, witness statements, and any additional information to ayoos@kannapolisnc.gov within 24 hours of the
incident.
FOR RISK MANAGEMENT USE ONLY
CITIZEN INJURY/
PROPERTY DAMAGE REPORT
Return this report to Risk
Management within one business
day of the first notice of loss.
This report is for information only and does not
constitute legal notice of claim.
Date Received __________________________________ Date Claim Filed ______________________________ Claim # _____________________________
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