HomeMy WebLinkAboutIncident Report FiberIncident report
Please complete only the applicable portion(s).
Member name: Member contact person: Member phone:
Location of incident:
Date & time of incident
Property damage
Property damage (Please provide details of loss and extent of damage): Estimated
amount of
loss:
Name of person(s) involved: Phone:
Witnesses: Police report filed? Agency: Report #:
Yes No
Attach supporting materials; police reports, pictures, repair estimates, or claims details of any kind
Vehicle accident – Your vehicle
Vehicle #: Year: Make: Model:
License # & state: VIN:
Driver name: Address:
DOB: Phone: Drivers’ license number & state:
Vehicle owner: Address: Other insurance:
For what purpose was vehicle being used at the time of the accident?: Is driver
employed
by the city?
Date of last
defensive
driving class:
Yes No
Address where vehicle may be seen: Estimated repair cost:
Specify area of damage on vehicle:
Police notified? Traffic citations issued? If so, to whom?
Yes No Yes No
Driver statement:
Witnesses:
Vehicle accident – Other vehicle
Other
Return completed form to:
AWC RMSA
1076 Franklin St SE
Olympia, WA 98501-1346
Or email the completed form to RMSA at rmsaclaims@awcnet.org
This form must be completed by members only. This form does not satisfy claims for damages reporting/filing
RCW 4.96.020.