Commercial Equipment Incident Report

This field is for validation purposes and should be left unchanged.

About You

Company Name(Required)

Your Name(Required)

First Last

Are you the best contact for the adjuster to reach out to?(Required)

Your Email Address(Required)

Your Phone(Required)

Preferred Method of Contact

Contact For Adjuster

Name(Required)

First Last

Email Address(Required)

Phone(Required)

Preferred Method of Contact

Incident Information

Date of Incident(Required)

Date Reported(Required)

Description of the Incident(Required)

Please include: incident, nature of injury, material damage, etc.

Did Emergency Officials Respond?

Responding Police Department

Police Report #

Current Status of Situation / Outcome

Upload Supporting Documents & Photos

Any files that help clarify the claim.

Drop files here or

Max. file size: 10 MB, Max. files: 10.

Location of Incident

Business Name

City State(Required)

Street Address City State

Were There Any Witnesses?

Witness Information

First Witness Name

First Last

First Witness Phone

Second Witness Name

First Last

Second Witness Phone

Third Witness Name

First Last

Third Witness Phone

Equipment Involved

Description of Equipment

Serial #

Is the Equipment Leased?(Required)

Please provide a copy of the lease agreement

Max. file size: 25 MB.

Do you have an estimate to repair?(Required)

Estimate Total

Please provide a copy of the repair estimate

Max. file size: 25 MB.

Equipment Operator Information

Name(Required)

First Last

Phone(Required)

About You

Contact For Adjuster

Incident Information

Location of Incident

Witness Information

Equipment Involved

Equipment Operator Information

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