LIABILITY CLAIM / INCIDENT REPORT
*Use this form to report: 1) any claim which caused bodily injury or property damage to a Claimant or 2) any incident that has potential to cause bodily injury or property damage to a Claimant.
(1) Name of MCCRMA Member:
(2) Member Department:
(3) Member Department Phone #:
(4) Reported By:
(5) Exact Location of Claim/Incident:
(6) Date of Claim/Incident:
(7) Time of Incident:
A.M. P.M.
(8) Date Reported By Department:
(9) TYPE OF CLAIM:
Bodily Injury Civil Rights Complaint Open Meetings Act Zoning Dispute Personal Injury
Property Damage EEOC/MDCR Complaint Freedom of Information Act Land Use Dispute Data Breach / Cyber
Claim Notice Only
CLAIMANT INFORMATION
(10) Claimant’s Name:
Name of Parent or Guardian (if applicable):
Claimant’s Address:
Claimant’s Telephone #:
Cell #:
Home #:
Work #:
BODILY INJURY INFORMATION PROPERTY DAMAGE INFORMATION
(11) Claimant’s Age: Date of Birth:
(18) Describe Property Damaged:
(12) Describe Injury:
(13) Part of Body Injured:
(19) Cause of Damage:
(14) Claimant’s Employer:
(15) Claimant’s Occupation:
(20) Extent of Damage:
(16) Did Claimant Lose Work Time?
Yes No
(17) Claimant Social Security #:
(21) Estimated Cost to Repair:
$
(22) Actual Cost to Repair:
$
(23) Name of Witness: Witness Address: Witness Telephone #:
1)
2)
3)
(24) Photographs Taken? Yes No
Photographs Attached? Yes
No
(25) Other Supporting Documents? Yes
No
Supporting Documents Attached? Yes
No
(26) Police Report #:
Police Report Attached? Yes No
(27) Please describe in detail how the claim/incident occurred (attach any supporting data):
(28) LAWSUIT
D. Please List Employees / Officials of Member who are Identified on the
Complaint:
1) 6)
2) 7)
3) 8)
4) 9)
5) 10)
A. Date of Service:
B. Method of Service: In Person Mail
C. Name of Person Served and Title:
(29) Submitted by: (30) Title: (31) Date:
FORWARD THIS REPORT TO: MMRMA CLAIMS
14001 Merriman, Livonia, MI 48154
Tele
hone:
734
513-0300 Fax:
734
513-0318
