Form Center

Incident Report

2. Incident Report

   Incident Report

4. Member City / Organization:*

5. Date*

7. This report shall be completed by the person who was present at the time the incident occurred or was discovered. Information is to be recorded immediately and the form forwarded to the Member's Claims Contact Person who will then forward a copy to Washington Cities Insurance Authority.

   This report shall be completed by the person who was present at the time the incident occurred or was discovered. Information is to be recorded immediately and the form forwarded to the Member's Claims Contact Person who will then forward a copy to Washington Cities Insurance Authority.

9. Name(s) of Member Personal Involved*

10. Department*

11. Phone*

13. Name(s) of Others Involved

14. Address

15. Phone

17. Date of Incident*

18. Time of Incident*

20. Location (Physical Address of Occurrence)*

22. Describe All Acts and Resulting Conditions in Detail*

24. What active measures, or assistance (if any) did Member Employees take?*

26. Reported by*

27. Date Signed*

29. Department*

31. Submit Form When Completed to Risk Manager

33. Received by Risk Manager Shelly Acero

Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field