Monroe County External Claim/Incident Reporting Form

Incident/Claim Information

Incident Type

Incident Date/Time

AM/PM

Incident Address

Incident City

Incident State/Province

Incident Country

Incident Description

Police File Number

Vehicle Involved?

Property Damage to Others?

Estimated Damages/Losses ($)

Please insert dollar amount only.

Reporter Details

"Reporter" is the person filling out this form

Involvement Type

First Name

Last Name

Birthdate

Phone

Mobile Phone

Badge Number

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

Description of Personal Injuries

Care from Emergency Medical Services?

Seek Medical Attention?

Health care provider's name

Do you wish to add Involved Persons?

"Involved Person" is an individual who is/may be involved with the claim/incident (directly or indirectly) being reported. (Examples include the claimant, witness to the Incident, lawyer, property manager, employees, etc.)

Involved Person Details

Involvement Type

First Name

Last Name

Birthdate

Phone

Mobile Phone

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

Sustained Injury?

Seek Medical Attention?

Care from Emergency Medical Services?

Description of Personal Injuries

Health care provider's name

Call Phone Number from Ambulance Call Report

Have you received any other medical aid?

Part of Body

Select multiple by holding "ctrl".

Nature of Injury

Select multiple by holding "ctrl".

To add another involved person, please select "Add another response" on the bottom-right portion of this section. This will open another section where information can inserted. If not required, please ignore.

3rd Party Involved Vehicle

Note: If you do not know the make of the vehicle, please put "N/A"

3rd Party Vehicle Make

If make not known, please insert "N/A"

3rd Party Vehicle Model

3rd Party Vehicle License Plate Number

3rd Party Vehicle Year

Vehicle Type

Description of Damages

To add another vehicle, please select "Add another response" on the bottom-right portion of this section.

Attachments

Do you wish to add Files/Attachments?

Note: There is a 25 MB per file size limit, a 35 MB total file size limit, and a 10 file limit per submission.

Please upload any supporting documents, images, invoices, or estimate of damages.

File Upload

To add more than one attachment, select "Add Another Response". To remove the additional file upload option, select "Remove".

Declaration

I have read, acknowledge and understand the consequences and agree with the statement above

I agree

NOTE: If you do not agree, Monroe County is unable to accept your on-line form as notice about your claim.

By submitting this form, you confirm that information in this document is correct to your knowledge.