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