Incident Report Form

1. Property Name:

1a. Property Phone Number:

1b. Location:

2. Address: *

3. Date: *

3a. Time:

3b. Date Reported to Prop. Mgmt: *

4. Who Reported this Incident to Property Mgmt?

4a. To whom was it reported at Property Mgmt?

5. Type of Incident: Property (Damage to WPC Property: Fire, Water, Vandalism, etc.) Liability (injuries and/or damage to property of others) Other

6. Name: *

6a. Phone: *

6b. Address: *

6c. Age: *

6d. Gender? * Male Female

6e. Type? Employee Resident Visitor Contractor Other

6f. Name:

6g. Phone:

6h. Address:

6i. Age:

6j. Gender? Male Female

6k. Type? Employee Resident Visitor Contractor Other

6l. Name:

6m. Phone:

6n. Address:

6o. Age:

6p. Gender? Male Female

6q. Type? Employee Resident Visitor Contractor Other

7. Name:

7a. Phone:

7b. Type? Management Employee Attorney Relative Witness Other

7c. Name:

7d. Phone:

7e. Type? Management Employee Attorney Relative Witness Other

7f. Name:

7g. Phone:

7h. Type? Management Employee Attorney Relative Witness Other

7i. Name:

7j. Phone:

7k. Type? Management Employee Attorney Relative Witness Other

7l. Name:

7m. Phone:

7n. Type? Management Employee Attorney Relative Witness Other

7o. Name:

7p. Phone:

7q. Type? Management Employee Attorney Relative Witness Other

10. Description of injuries/disease:

10a. Occupation:

11. Was medical treatment sought? yes no

11a. If so, when?:

11b. How? Ambulance/EMS Emergency Room Own Doctor 0Clinic

11c. Name and address of treating physician/hospital:

If injury required medical treatment, a Condition of Premises Report (page 4) must be completed. Employee injuries must be filled out by the employee’s supervisor.

12. Describe the extent of the damages:

13. Person(s) arrested:

13a. Report # (if applicable):

13b. Contractors Name & Phone Number (if applicable):

14. Is the tenant able to continue to occupy its suite? yes no

14a. If not, is substitute space available? yes no

15. Does the tenant have contents insurance? yes no

If yes, what is the:

15a. Name of Insurance Company:

15b. Policy #:

15c. Phone #:

16. Action taken:

17. What follow-up is needed?

18. Were the police notified? yes no

18a. Anyone arrested? yes no

18b. Report #:

18c. Person(s) arrested:

Person completing this report:

Date:

Property Manager or Supervisor:

Property Manager or Supervisor’s Phone Number:

Complete when ANY injury necessitates medical attention.

1. Date and time of investigation of accident:

2. Name of person(s) investigating:

2a. Did person conducting investigation witness the accident? yes no

3. Was place of accident lighted? yes no

3a. If no, please describe:

4. Weather conditions at time of accident:

4a. Is Snow/Ice Removal Log Available? yes no

If yes, attach a copy of the log to this report.

5. Was there any substance or object on the surface or near place of accident? yes no

5a. Please describe.

6. Were there any breaks, holes or obstructions involved? yes no

6a. Please describe.

7. Describe claimant’s footwear at the time of accident?

8. Was construction work, repairs or maintenance in progress at site at time of incident? yes no

8a. Or - recently performed near the incident site? yes no

8b. Name and address of person or company doing work:

9. Were pictures taken of accident scene? yes no

Additional comments:

Remember: Save all evidence until repair or disposal is authorized by the adjuster.

Company Name:

Building Address:

Suite:

Service Start Date:

Service End Date:

Please enter start and end time.

Hours of Service (Start Time):

Hours of Service (End Time):

Complete when ANY injury necessitates medical attention.

Hours of Service (Start Time):

Hours of Service (End Time):

Please enter start and end time.

Hours of Service (Start Time):

Hours of Service (End Time):

Please enter start and end time.

Hours of Service (Start Time):

Hours of Service (End Time):

Name:

Phone:

Identify Image: *