Fillable RISK DIVISION Life. Well Crafted. INCIDENT REPORT Todd (City of Hickory)

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RISK DIVISION Life. Well Crafted. INCIDENT REPORT Todd (City of Hickory)

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Safety-Risk Incident Form; revised 12/2013
Life. Well Crafted.
RISK DIVISION
INCIDENT REPORT
DATE OF INCIDENT: TIME:
DATE OF REPORT: TIME:
REPORT TAKEN BY:
CLAIMANT:
ADDRESS:
HOME PHONE:
WORK PHONE:
ADDRESS OF INCIDENT:
WAS A CITY EMPLOYEE INVOLVED:
YES
NO
NAME:
ADDRESS:
HOME PHONE:
WORK PHONE:
DEPARTMENT:
LARS CODE:
TYPE OF CLAIM: Property
Automobile General Liability Other
CLAIMANT’S AUTO: Year: Make
Model
CITY VEHICLE: Year: Make
Model
VIN#
WHAT HAPPENED:
AMOUNT OF ESTIMATED DAMAGE $
CONTACT PERSON: PHONE:
CALLED BROOME INSURANCE
YES
NO
Date: Time:
Todd Shoebridge, Risk Manager
City of Hickory
PO Box 398
Hickory, NC 28603
Phone: (828) 323-7442
Fax: (828) 323-7550
email: tshoebridge@hickorync.gov
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RISK DIVISION Life. Well Crafted. INCIDENT REPORT Todd (City of Hickory)

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Completed 23 January 2021

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