Date of Loss___________ Time _______ ORM Location Code________________________________
Names of All Parties Involved __________________________________________________________
? ____ ? ______ ? ___________________________________
Description of Incident and Action Taken:
(Attach additional information, official reports & photos [see next page])
Type and extent of injury known: _________________________________________________________
Name of injured Party: ___________________________________Phone _________________________
Address: _________________________________City/State ___________________________________
Name/Address of Attorney: ______________________________________________________________
Name: _____________________________________________Phone ___________________________
Address: __________________________________City/State __________________________________
Name: _____________________________________________Phone ___________________________
Address: __________________________________City/State __________________________________
Reported by: ___________________________________Date: ________________________________
Contact Person: _________________________________Phone ________________________________
Description of Property & Damage (Age/Make/Model/Cost of Repairs) ____________________________
(Attach additional Information if available)
Name of Owner: _____________________________________Phone ___________________________
Address: __________________________________City/State __________________________________
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Who was Notified? Police Agency Others
Injury Information:
Damage to Others’ Property:
Use this form to report incidents affecting members of the general public or others while on State property which you
could reasonably result in a claim against the State. Do not use for auto accidents or Workers Compensation
Send completed report to:
Submit by Email
Print This Form
Print This Form
Submit by Email
Were photographs taken? Please include originals (photocopies are seldom adequate).
Was a police report / incident report created? Please include copy(ies).
The more detail you can supply, the better.
For example, when reporting slip/trip and fall incidents:
Was the claimant wearing glasses? What type of shoes? What kind of soles? Does claimant have any
handicaps/disabilities? Was he/she on any medications? What kind of surface was claimant walking on? What
was the lighting condition? Was surface wet or dry? Any debris present? Any defects? Surface irregularities?
For stolen items,
Were they se
cure? What kind of lock? Who has keys or access? Supply brand name, original cost, date of
For damaged personal property,
Give brand name, original cost, date of purchase, where can item be seen?
For broken furniture etc,
Was broken item removed from circulation? Was it stored for examination by investigator? Where stored? (Do not
repair or discard broken items involved in a claim until told to do so by ORM)