If a non-state employee is injured or property of others is damaged (or alleged) because of the State’s operations, whether negligent or not, report the claim directly to the Department of Administrative Services, Risk Management Services by calling 404-656-9490 or email to: [email protected]. Keep your answers brief and to the point.

This form should be completed if someone has been injured or property (including motor vehicles) has been damaged. Alt. Phone Number: ( Date of Birth: / What activity was going on? 4. After the incident, what action was taken? (Please be specific.) 5. If applicable, provide the name of the facility where the injured party was taken: . 6.

2024年9月30日 · An incident report is used to formally document an event that involves an accident, injury, property damage, or other unusual activity. Commonly used in the workplace, an incident report can help employers reduce liability by addressing problematic employees or processes in an effort to prevent harmful incidents from recurring.

PLEASE EMAIL YOUR COMPLETED FORM TO [email protected] OR CALL 1.800.238.6225. DID THE LOSS OCCUR AT THE LOCATION ADDRESS? (IF “NO”, ADDRESS WHERE LOSS OCCURRED) YES NO. WERE THERE ANY INJURIES? IS THERE BUILDING DAMAGE TO THE PROPERTY OF OTHERS? IS THE INTERIOR OF BUILDING NOW EXPOSED TO OUTDOORS AND UNPROTECTED?

2022年12月13日 · Complete this form if a non-employee is injured. Report the incident directly to the General Manager. When authorized, report claims to your insurance carrier or a Kapnick Claim Advocate.

Property/Liability Loss Notice Form (PDF) Before completing this form, download and save the PDF file to your computer. Then complete the form using Adobe Reader or Acrobat to ensure your changes take effect.

Instructions: This form should be completed witness to an accident that results in injury or illness. The form should be as soon as possible (24 hrs) and submitted to the injured employee’s immediate supervisor. Did the incident involve property damage? Was a …

Complete this form if a non-employee is injured. When authorized, report claims toyour insurance carrier or Sweet Insurance. Do not delay reporting the claim because you do not have all the information regarding the incident.

Use this form to report incidents affecting members of the general public or others while on State property which you believe could reasonably result in a claim against the State. Do not use for auto accidents or Workers Compensation

Report the incident to your manager and/or insurance company immediately. Please use a new form for each claimant. In this document, “claimant” means injured person, a person who may have been injured, or a person whose property was or may have been damaged. Insured: Policy #: Insured contact (Name, Phone, Email): Incident date and time (am ...