Hilbert Communications Asset/Property Damage Report

• Company (KES Excavating, Red Tail Towers, Bug Tussel Wireless)

• Type of Property Damage (Vehicle Accident, Property Damage, Utility Hit, Environmental Damage)

• Address of Damage/Incident

  Yes

  No

  N/A

• Date Damage/Incident Occurred

  Date

• Date Damage/Incident Reported to Supervisor

  Date

• Person Completing Report

• Has a report been filed with the local authorities

  Yes

  No

  N/A

• If so, who?

• Report #

Employee

• Company (KES Excavating, Red Tail Towers, Bug Tussel Wireless)

• Name

• Job Title

• Start Time

  Date
• Employee Address
  Address

• Employee Phone Number

• Supervisor

• Was employee sent for post incident drug/alcohol testing?

  Yes

  No

  N/A
Witnesses

• Name

• Job Title

• Contact Information

Property Owner Information

• Name of Property Owner

• Phone Number

• Email

• Generally describe how the damage/incident occurred

• Type of Asset

• Asset Number

• Generally describe damage to equipment

• Generally describe what happened

• Was any vehicle towed away from the scene

  Yes

  No

  N/A

• Were any employees sent for drug or alcohol testing

  Yes

  No

  N/A

• Who

• General description of damages, what happened and what was done to minimize further damage

• Name of utility/damaged party

• Was the utility documented on any prints

  Yes

  No

  N/A

• Location requests made

  Yes

  No

  N/A

• Date/Time

  Date

• Were locates accurate

  Yes

  No

  N/A

• Date locates cleared

  Date

• How were utilities marked

  Select

• Locate Ticket Number

• Located By

• I certify that the information provided on this report is true and complete to the best of my knowledge.

• Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against the company, submits and application, or files a claim containing false or deceptive is guilty of insurance fraud.

• If I seek medical attention, I will notify the doctor that Hilbert Communications will accommodate medical restrictions for work-related incidents.

• I will contact the Safety Department or my Supervisor after each doctor visit and will follow all medical restrictions on and off the job.

• Employee Name

  Sign

• Supervisor Name

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