Initial Report Information
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Company
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Type of Property Damage
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Address of Damage/Incident
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Date Damage/Incident Occurred
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Date Damage/Incident Reported to Supervisor
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Person Completing Report
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Has a report been filed with the local authorities
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If so, who?
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Report #
Crew Members Involved
Employee
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Company
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Name
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Job Title
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Start Time
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Employee Address
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Employee Phone Number
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Supervisor
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Was employee sent for post incident drug/alcohol testing?
Witnesses
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Name
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Job Title
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Contact Information
Property Owner Information
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Name of Property Owner
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Phone Number
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Email
Incident/Damage Information
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Generally describe how the damage/incident occurred
Equipment Damage Information
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Type of Asset
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Asset Number
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Generally describe damage to equipment
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Generally describe what happened
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Was any vehicle towed away from the scene
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Were any employees sent for drug or alcohol testing
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Who
Property/Environmental Damage
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General description of damages, what happened and what was done to minimize further damage
Utility Damage
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Name of utility/damaged party
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Was the utility documented on any prints
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Location requests made
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Date/Time
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Were locates accurate
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Date locates cleared
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How were utilities marked
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Locate Ticket Number
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Located By
Signatures
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I certify that the information provided on this report is true and complete to the best of my knowledge.
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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.
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If I seek medical attention, I will notify the doctor that Hilbert Communications will accommodate medical restrictions for work-related incidents.
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I will contact the Safety Department or my Supervisor after each doctor visit and will follow all medical restrictions on and off the job.
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Employee Name
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Supervisor Name
