|
Miami Valley Risk
Management Association
Craig Blair, Claims
Manager
For a
first report of loss or injury form, with active dropdown boxes, that can
be downloaded to your computer, contact Craig Blair at the MVRMA office:
937/438-8878 or cblair@mvrma.com.
FIRST
REPORT OF LOSS OR INJURY
Claim Type (check all
which may apply):
|
1)
A City Property Damage Claim (above $1,000 threshold)
2)
A City Liability Claim (all claims)
3) Subrogation
claim
4) An incident
or event, but only for informational purposes |
|
|
City: |
|
Department: |
|
|
|
|
|
Date of Loss: |
|
Date of Report:
|
|
|
|
|
|
Employee Preparing
Report: |
|
Employee Email
Address or Phone#: |
|
|
|
|
|
Description of claim or incident:
(Field below expands as
you type) |
|
|
|
Description of
damage to city property:
(Field below expands as
you type) |
|
|
|
Third-party
claimant’s information: |
|
|
Name: |
|
Phone #: |
|
|
|
|
|
|
|
|
|
Address: |
|
|
|
|
|
|
|
|
|
City & State: |
|
Zip Code: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Description of injuries or property damage to third-party claimants:
(Field below expands as you type) |
|
|
Please forward
the supervisor’s investigation report, police report, repair estimate, or
any other information relating to the loss. (1/08)
|
