EmailMe Form - Other Incident Submission Form

Department Name: *

Person Submitting Claim: *

Email Address *

Incident Date: *

MM / DD / YYYY

Incident Type: *

Incident Number:

Incident Location: *

Physical Address Required

County and State: *

Person / Company Name: *

Address: *

Include City, State, and Zip Code

Phone Number: *

Insurance Carrier: *

Insurance Policy Number: *

Privately bill this company / individual if insurance denies payment, does not pay in full, or no insurance is supplied? *

List all unit numbers separated by commas. (ie., Engine 72, Engine 78)

Engines:

Tankers:

Rescues:

Aerial / Ladder Trucks:

Utility / Brush Trucks:

Chief / Command Vehicles:

Any Specialty Equipment?

HazMat Trailer, Rescue Trailer, Light Tower, etc.

Amount of time on the Incident: *

Hours and Minutes

Number of Personnel that Responded: *

Services you provided: *

Extinguishment, Rescue, Traffic Control, etc.

Damaged Equipment:

Any equipment / gear receive damage while on scene? If so, list name, type, and cost to clean / fix / replace.

Incident Narrative: *

Describe the incident what actions you took. Be detailed as possible.

File Upload

If you have any documents that are related to this incident that you need to include upload them here.