Fillable Incident Report Form MMA Exterior Door Proximity Reader Plan

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Incident Report Form MMA Exterior Door Proximity Reader Plan

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City of Bangor Incident Report
Department of Safety and Environmental Management
Created: 5/28/2020
Revision: New 1 | Page
This form will be used by City of Bangor employees to document an incident that could lead to a potential insurance
claim. It is important to document and report the incident to the Department of Safety and Environmental
Management as soon as possible in order a claim file can be created and our insurance representatives can be notified.
Report Completed By:
Today’s Date:
mm
dd
yyyy
Date of Incident:
Type of Incident (
check all that apply
):
Property Damage 3
rd
Party Injury
Sewer Back-up Environmental
Other: _____________________________________
dd
yyyy
Time of Incident: AM
PM
Name of Person(s) Involved:
1.
2.
3.
Phone Number(s):
1.
2.
3.
Location of Incident (include physical address):
Description of the Incident:
Included with the Report: Police Report Photos / Video
Medical Records / Bills Estimate / Receipts Other: __________________________
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Incident Report Form MMA Exterior Door Proximity Reader Plan

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Completed 11 July 2020

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