Liability Report Form Date of Occurrence: Address of Occurrence: Staff Name Reporting Accident: Contact Phone Number: Description of Occurrence: Injuries Name, Address, Phone: Description of Injuries: Medical Treatment: Property Damage Name, Address, Phone: Description of Property Damage: Witnesses: Police Called (Department, Case Number): Photos Obtained? Additional Information: Privacy Policy Confirmation I agree to be contacted by Alera Group in accordance to their Privacy Policy as described below. By submitting this form, I agree I want to receive additional information from Alera Group, including by email, phone, and mail to the contact information I am submitting. I consent to Alera Group, its subsidiaries, and its service providers, processing my personal information for these purposes and as described in the Privacy Notice. I understand that I can withdraw my consent at any time. Δ Report within 24 hours
