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2. The City of Watauga is part of the Texas Municipal League Intergovermental Risk Pool (TMLIRP). When an incident occurs involving City property, or occurrs at any City facility the City Secretary's Office must act quickly to ensure all necessary documentation is gathered, processed and filed in an efficient and prompt manner. Please submit this form to the City Secretary's Office, within 48 hours of the occurrence. Please include any reports, incident reports, pictures, or statements which may assist the City Secretary's Office in processing the claim.
   
   THIS FORM IS NOT FOR REPORTING AN INCIDENT TO HUMAN RESOURCES.
4. Date and Time of Occurrence?*
   Date and Time of Occurrence?

   Date and Time of Occurrence?
5. 
   
6. Location of Occurrence?*
8. Was there city property damaged?*
   -- Select One --YesNo
9. What was damaged?*
10. Was there a police report completed?*
    -- Select One --YesNo
12. Is the damage estimated to be over $2,500?*

    1. Yes
    2. No
    3. Not Sure?
13. Were any employees injured?*
    -- Select One --YesNo
14. If there were employee injuries-has Human Resources been notified? *
    -- Select One --YesNo
16. Were there any non-employee injuries?*

    1. Yes
    2. No
17. Was there an EMS report completed ?
    -- Select One --YesNo
19. Please upload any pertinent accident/incident reports, pictures or statements.
    NOTE: If employees have witnessed the occurrence, please provide a statement describing what you witnessed. Please upload the statement below.
21. Upload 1:
23. Upload 2:
25. Upload 3:
27. Upload 4:
29. Upload 5:
31. Upload 6:
33. Upload 7:
35. Upload 8:
37. Upload 9:
39. Upload 10:
41. Name and Title of who is submitting report:*
42. 
    
44. Office Phone Extension:*
46. Email Address:*
48. 
    
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

* indicates a required field