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.
 

Report within 24 hours