Third Party Incident Form

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Claimant Name *

Today's Date

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Address *

Phone Number *

Incident Date

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Incident Time *

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Incident Time AM

Incident Time PM

Incident Location *

Incident Type *

Near Miss

Property Damage

Injury

Unsafe Condition

Describe the Incident / Accident *

Please describe the incident/accident fully (what happened and why; identify unsafe conditions and/or actions)

Describe Property Damage and/or Bodily Injury

Describe Any First Aid / Medical Treatment (when and by whom)

Was the Accident Reported? *

Yes

To What Agency? *

List Names and Phone Numbers of Witnesses *

Attach a Photo

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf.

Contact Information

Finance Department

39250 Pioneer Blvd
Sandy, OR 97055
(503) 668-5533