Commercial
Residential
Property Damage 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
Discovered by Whom
(Required)
Person's Status
(Required)
Property Manager
Maintenance Technician
Other Staff
Tenant
Visitor
Contractor
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
Victim / Injured Information
Victim / Injured
(Required)
Yes
No
Person's Name
(Required)
Person's Status
(Required)
Property Manager
Maintenance Technician
Other Staff
Tenant
Visitor
Contractor
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
Was Medical Attention Required?
(Required)
Yes
No
Notification Information
Who Was Notified
(Required)
Employee
Other
Employee's Name
(Required)
Title
(Required)
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 Name
(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
Name
(Required)
Phone
(Required)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
United States
Country
Second Witness
Name
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
United States
Country
Incident Details
Exact location where incident occurred
(Required)
Was all lighting functional in the area of accident
(Required)
Unknown
Yes
No
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
Describe, in detail, what happened
(Required)
Additional Comments in Regard to this Report
(Required)
(Follow up notes, or action taken after the event)
Who was involved?
(Required)
Please Explain
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
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
File
Accepted file types: jpg, jpeg, gif, png, webp, bmp, pdf, Max. file size: 300 MB.
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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
Shari Williams
Meaghan Wills
Tristian Witte
_____________________________________________
Amanda Burchfield - Director
Sean Davis - Director
Kelly Foral - Director
Chelsea Kunzler - Director
Kim Root - Director
_____________________________________________
Stacie Anderson - Test Purposes
