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2. Contact Information
   Please complete the contact portion for the person that is completing the form, so we can contact you with any questions.
4. First Name
5. Last Name
7. Phone number
8. Email address
10. Address1
12. Address2
14. City
15. State
16. Zip
20. Check Report Type*

    1. Accident
    2. Incident
    3. Lost/Damaged Property
    4. Hazardous Condition
    5. Citizen Claim
21. Date and Time of Occurrence*
    Date and Time of Occurrence

    Date and Time of Occurrence
22. Actual Location of Occurrence*
24. Name of Employee Involved:*
25. Employee Job Title and Department*
27. Was there any other employee involved in this occurrence?*

    1. Yes
    2. No
29. Name, Title and Department of Employees incolved in this occurrence*
31. Was there any Citizens involved in this occurrence?*

    1. Yes
    2. No
33. Name, Address & Telephone number of Citizen (s) involved in this occurrence*
35. Was any one injured during this occurrence?

    1. Yes
    2. No
37. Name of Injured and Description of Injuries*
39. What level of treatment was needed*

    1. No treatment Required
    2. First Aid Only
    3. Professional Medical Treatment
41. Was any property involved in this occurrence?*

    1. Yes
    2. No
43. Description of Property Involved*

    1. Vehicle
    2. Other property
45. Vehicle Data/ Year
46. Make
47. Vin #
49. Model
50. City Property Tag #
51. Vehicle #
53. Name of Driver
57. Property Data Make
58. Model
60. Serial #
61. City Property Tag #
63. DESCRIBE VEHICLE DAMAGE OR LOST/DAMAGED PROPERTY
65. ESTIMATE OF REPAIR OR REPLACEMENT COSTS:$
67. DESCRIBE HOW THE EVENT (ACCIDENT, INCIDENT,...) OCCURRED: Be sure to answer Who?; What?; When?; Where?; Why?; and How?
69. CAUSAL FACTORS: Events and conditions that contributed to the occurrence. Include those identified through the use of the National Safety Council's "Guide for Identifying Causal Factors and Corrective Actions" located in Section 6 of the "City of Cocoa Safety and Loss Control Program Safety Manual"
71. CORRECTIVE ACTIONS: Actions that have been or will be taken to prevent re-occurrence. Include those identified through the use of the National Safety Council's "Guide for Identifying Causal Factors and Corrective Actions" located in Section 6 of the City of Cocoa Safety and Loss Control Program Safety Manual."
73. Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. I have reviewed, understand and acknowledge the above statement.
75. Signature*
    By typing my name in this form, I affirm the accuracy of information provided on this application. I understand that this constitutes a legal signature and confirms that I agree to the above terms.
76. Date
80. Prepared By
81. Date
83. Division
84. Date
88. Approved By
89. Title
91. Division
92. Date
94. Submit completed form to HR within 24 hours
    If a vehicle is involved, Fax a copy to Tony Jones, Fleet Manager @7672 within 24 hours
Leave This Blank:


96. 1. Receive an email copy of this form.
97. Email address

    This field is not part of the form submission.

98. Submit Submit and Print

* indicates a required field