Jeffersontown Fire Protection District
Incident Report Request
Please read the information on Page 2 before completing.
Incident Date:
Incident Address:
Incident Type:
Fire Medical Assistance Hazardous Materials Other:
Person and Business/Agency Requesting Report
Name (first, middle initial and last):
Business Name:
Mailing Address:
City: State: ZIP
Daytime Telephone:
Insurance on Damages: Yes No
Requesting Party is the:
Owner Owner’s Attorney
Owner’s Insurance Agent Occupant/Tenant
Occupant/Tenant’s Attorney Occupant/Tenant’s Insurance Agent
Beneficiary of Deceased Patient Other:
For Insurance Company Representatives
Insurance Company Name:
Person(s) Represented:
Policy Claim Number:
~~~~~~~~~~~~~~~~~~~~ For Office Use Only ~~~~~~~~~~~~~~~~~~~~
Incident Number: Date Provided:
Request Received by (print): Date:
Authorized by (FD
representative signature):
Submit by Email
Print Form
click to sign
click to edit
Incident Report Request Instructions
If completing this form manually, please print all information.
This report may be submitted in the following formats after completion:
1. US Mail (Please include a self-addressed stamped envelope):
Jeffersontown Fire Protection District
10540 Watterson Trail
Jeffersontown, KY 40299
2. Electronically:
Complete this form using Acrobat Reader, then submit by clicking on the “Submit by Email” button in
the top, right-hand corner of Page 1.
3. Email:
Print this form and complete it manually. Once completed, scan the form and email it to:
4. Fax:
Print this form and complete it manually. Once completed, fax the form to: 502.267.5217.
Please allow up to three (3) business days for response to the incident report request. Thank you.