General Liability Reporting Form

General Liability Report
Risk Management Division
Phone (704) 336-3301 Fax (704) 336-7548

Please complete as much information as possible. Any field that is preceded by an "*" is a required field.
The form cannot be submitted until all required fields are completed.

*Select Organization

*Department

*Division

Dept. Code

Called to Risk Management By:

Date:

Time:

Police Report Number

INCIDENT INFORMATION

*Incident Date	Time	*Weather at time of Incident
*Address Where Incident Occurred
* Description of Incident

*Was a citizen's vehicle involved?

Year	Make/Model	Tag#
Where is the Vehicle?

DRIVERS INFORMATION
Name
Address	City/State/Zip / /
Phone Number (Home)	Phone Number (Work)

OWNER'S INFORMATION (If different from driver)
Name
Address	City/State/Zip / /
Phone Number (Home)	Phone Number (Work)
Estimate of Damages $
Damage Description

Insurance Company	Policy Number
Address	City/State/Zip / /

PROPERTY OWNER'S INFORMATION (other than vehicle)
Name
Address	City/State/Zip / /
Phone Number (Home)	Phone Number (Work)
Estimate of Damages $
Damage Description

NUMBER OF PERSONS INJURED

Injuries?		Fatalities?
*Please select the number of Persons Injured

1) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

2) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

3) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

4) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

5) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

6) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

7) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

8) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

9) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

10) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

11) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

12) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

13) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

14) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:

15) Name		Telephone # Home: Work/Other:
Address		City/State/Zip / /
Type of Injuries		Taken to:


WITNESSES (If any)

*Please select the number of Witnesses to Enter
1) Witness Name	Address
City/State/Zip / /	Phone #

2) Witness Name	Address
City/State/Zip / /	Phone #

3) Witness Name	Address
City/State/Zip / /	Phone #

4) Witness Name	Address
City/State/Zip / /	Phone #

5) Witness Name	Address
City/State/Zip / /	Phone #

6) Witness Name	Address
City/State/Zip / /	Phone #

7) Witness Name	Address
City/State/Zip / /	Phone #

8) Witness Name	Address
City/State/Zip / /	Phone #

9) Witness Name	Address
City/State/Zip / /	Phone #

10) Witness Name	Address
City/State/Zip / /	Phone #

11) Witness Name	Address
City/State/Zip / /	Phone #

12) Witness Name	Address
City/State/Zip / /	Phone #

13) Witness Name	Address
City/State/Zip / /	Phone #

14) Witness Name	Address
City/State/Zip / /	Phone #

15) Witness Name	Address
City/State/Zip / /	Phone #

Attach additional information you may have to this report. Forward all additional info to Risk Management as it becomes available.
Telephone 704-336-3301 Fax 704-336-7548 TTY 704 336-5943 For Hearing Impaired


*Supervisor Name	*Phone #	*Date
A copy of this report automatically goes to Risk Management. Please enter any additional email addresses that you desire a copy to go to.
Employee Email: (Separate Multiple Emails by commas)
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