|
| City:
______________________________
|
Department: ______________________________
|
| Date of Loss:
_______________________
|
Date of Report:
____________________________
|
Employee Preparing
Report: ___________________________________________________________
|
| In the space below, or on
an attached sheet, please provide a brief description of the claim or
incident:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
|
| Description of injuries to city employees and/or damage to city property:
__________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
|
|
| Names, addresses, and
phone numbers of third-party claimants:
_______________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
|
| Description
of injuries or property damage to third-party claimants:
______________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
|
|
Please forward
the supervisor’s investigation report, police report,
repair estimate, or any other information relating to the loss. (
2/99)
|
