RFTW Incident Report

RFTW Incident Report

(ONE FORM PER VEHICLE)

"*" indicates required fields

- Please Complete all Sections -

Emergency Claims After Hours: (952) 467-6111

Route Name*
MM slash DD slash YYYY
Incident Time*
:
Vehicle Type*

Max. file size: 2 MB.
Incident Type*

Location of Incident/Mishap*

Incident Location/Address

Injured Person*

Signed Waiver*
(Director of Risk Management)

PLEASE ATTACH A COPY OF THE EXECUTED WAIVER WITH THIS INCIDENT REPORT.

Information of Injured Person or Property Owner:

Name, Injured Party*
Address, Injured Party*
Gender, Injured Party*
Transported to Hospital*
Admitted to Hospital*
Hospital Address*

Witness Info

Witness #1 Name
Witness #1 Address
Witness #2 Name
Witness #2 Address

Reporting Party Info

Reported by*
Title, Reporting Party*

Address, Reporting Party*

IF ANY OF THE FOLLOWING OCCUR PLEASE REPORT WITHIN 24 HOURS

  • Cord Injury - paraplegia, quadriplegia
  • Amputations - requiring a prosthesis
  • Head injury including loss of consciousness, bleeding from ears/nose/head Brain damage affecting mentality or central nervous system - such as permanent disorientation, behavior disorder, personality change, seizures, motor deficit, inability to speak (Aphasia), hemiplegia or unconsciousness (Comatose)
  • Blindness
  • Burns - involving over 10% of body with third degree or 30% with second degree
  • Multiple fractures - involving more than one member or non-union of any part of the body
  • Nerve damage causing paralysis and loss of sensation in arm and hand (Brachia} Plexus Nerve Damage)
  • Massive internal injuries affecting body organs
  • Fatalities
  • Rape/Sexual Assault
  • Injuries involving multiple parties in the same accident
  • Significant property damage
  • Medical transport of injured party
This field is for validation purposes and should be left unchanged.