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Universal Report Form

  1. Contact Information

    Please complete the contact portion for the person that is completing the form, so we can contact you with any questions.

  2. Check Report Type*

  3. Was there any other employee involved in this occurrence?*

  4. Was there any Citizens involved in this occurrence?*

  5. Was any one injured during this occurrence?

  6. What level of treatment was needed*

  7. Was any property involved in this occurrence?*

  8. Description of Property Involved*

  9. 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.

  10. 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.

  11. 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

  12. Leave This Blank:

  13. This field is not part of the form submission.