Date of Incident Time of Incident Location of Incident Was Police Department Notified yes no Fire Department/EMS Please provide a brief description of the type of damage: Date am yes pm no Injury to Person Damage to Property Other (describe) Vehicle (see other side) Name of Party Phone Address (include complete address, with street address, city, state and zip) Briefly Describe What Happened: Cause of damage/injury Contributing Factors Is injured party a Town employee Did the injured party refuse medical attention yes Has Supervisor been notified no Witnesses: Name Address Phone Name Address Phone Name Address Phone Follow up Action Date 1 Comments Incident/Property Damage Report Form Updated April 7, 2015 Vehicle Information Vehicle 1 Vehicle year Vehicle Make Vehicle Model Vehicle plate Vehicle Insurance Carrier Vehicle Owner Drivers relationship to Employer Purpose of use Vehicle used with permission (if no, explain) Person involved (first last name) Driver s License No..
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