Commercial
Residential
Personal Injury / Liability Related Incident Report
Instructions
Third Party & Witness Statement
Form rejected by Regional Property Manager. Reason:
Date of Report
(Required)
MM slash DD slash YYYY
Report Completed By: Name and Title
(Required)
Email
(Required)
Property Name
(Required)
Property Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
United States
Country
Incident Information
Date of Incident
(Required)
MM slash DD slash YYYY
Time of Incident
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Type/Description of Occurrences
(Required)
Accident/Safety/Hazard
Slip and Fall
Criminal
Other
Discovered by Whom
(Required)
Person's Status
(Required)
Tenant
Visitor
Contractor
Employee
Other
Name
(Required)
Company Name/Title
(Required)
Home Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
United States
Country
Type of Crime
Description
Victim / Injured Information
Victim / Injured
(Required)
Yes
No
Person's Name
(Required)
Person's Status
(Required)
Tenant
Visitor
Contractor
Employee
Other
Company Name/Title
(Required)
Home Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
United States
Country
Type of Injuries
Notification Information
Who Was Notified
(Required)
Employee
Tenant
Visitor
Contractor
Other
Employee's Name
(Required)
Title
(Required)
Home Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
United States
Country
Other's Name
Notification Date
(Required)
MM slash DD slash YYYY
Notification Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Notification Made By
(Required)
Email
Phone
In Person
Emergency Response Information
Emergency Response
(Required)
Yes
No
Police Notified
(Required)
Yes
No
Time Responded
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Police Officer’s Contact Info
(Required)
Accident/Crime Report #s
Ambulance/Fire Department Notified
(Required)
Yes
No
Time Responded
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Unit/Dept Responding
Witness Information
Witness
(Required)
Yes
No
First Witness
Person's Status
(Required)
Tenant
Visitor
Contractor
Employee
Other
Name
(Required)
Phone
(Required)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
United States
Country
Second Witness
Person's Status
Tenant
Visitor
Contractor
Employee
Other
Name
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
United States
Country
Suspect Information
Suspect Information
(Required)
Yes
No
Height
Weight
Hair Color
Eye Color
Race
DOB/Age
Gender
Male
Female
Distinguishing Marks
Vehicle Information
Vehicle Information
(Required)
Yes
No
Make
Model
Color
License Plate # & State
Driver's Name
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
United States
Country
Driver's Insurance Info
Policy #
Driver's License #
Other Insurance Info
Policy #
Driver's License State
Incident Details
Exact location where incident occurred
(Required)
Were you working, going to or leaving work?
(Required)
Yes
No
Who was involved?
(Required)
Theft
(Required)
Yes
No
List items taken, description and approximate value
Injury
(Required)
Yes
No
Was Medical Attention Required?
(Required)
Yes
No
Please Explain
Describe, in detail, what happened
(Required)
Additional Comments in Regard to this Report
(Required)
(Follow up notes, or action taken after the event)
Personal Injury
Did the accident occur indoors or outdoors?
(Required)
Indoors
Outdoors
Weather Conditions
(Required)
Please describe the weather conditions and attach a weather report from both of the following addresses:
http://www.weather.gov/climate/index.php?wfo=oax
http://www.wunderground.com/history
Was all lighting functional in the area of accident
(Required)
Unknown
Yes
No
When was the area last swept, cleaned, mopped, plowed or cleared (give specific date and time)?
(Required)
Was any debris on the ground next to the slip and fall site?
(Required)
Unknown
Yes
No
Describe
Required: Please upload any documents in regard to this incident, such as: photos, weather report, snow tickets, snow logs, property map, witness statement, police report or any other documentation.
If you have more than six attachments, or if you have a Word, Excel or video file, please email those directly to your Regional Manager AND
insuranceadmin@lundco.com
.
File Upload
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File Upload
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File Upload
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File Upload
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File Upload
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File Upload
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
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File Upload
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File Upload
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File Upload
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File Upload
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File Upload
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File Upload
Who took the photos?
(Required)
Date
(Required)
MM slash DD slash YYYY
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Has a Forced Placed Liability Claim been filed?
(Required)
Yes
No
Your Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Regional PM Name
(Required)
Please select below
Victoria Bishop
Lynnsey Danker
Kasey Douglas
Nabil Grado
Charlie Moore
Laurel Mueller
Shannon Noudaranouvong
Tracy Ramirez
Shannon Rhodes
Madison Sillivan
Lindsay Trout
Ashley Scott-Johnson
Shari Williams
Meaghan Wills
Tristian Witte
_________________________________________________
Amanda Burchfield - Director
Sean Davis - Director
Kelly Foral - Director
Chelsea Kunzler - Director
Cassandra McMullin - Director
Kim Root - Director
_________________________________________________
Stacie Anderson - Test Purposes
