REAL ESTATE RENTAL FORM
Maintenance/Management

(Download link is below the form)

MAINTENANCE/MANAGEMENT - ACCIDENT REPORT

 ACCIDENT / INCIDENT REPORT

TYPE OF INCIDENT: Accident___ Fire__ Medical Emergency__ Crime__ Other__

Address of where happening occurred:_____________________________________

State details regarding any injuries or damages that occurred: (use back of page if needed)

____________________________________________________________________

____________________________________________________________________

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Name of residents involved: ______________________________________________

Were any individuals involved that are not current residents of above address?_______  If so, why were they on the premises?_______________________________

Name, addresses and phone numbers of any individuals other than residents of premises.

____________________________________________________________________

____________________________________________________________________

Any witnesses? If so, please give their names, addresses and phone numbers. In your opinion, do you know what may have caused the incident or accident? If so, what?

____________________________________________________________________

Please give the reasons why the cause may have been what you suspect.

____________________________________________________________________

____________________________________________________________________

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Name of insurance company and policy numbers of all parties involved (including yours)

____________________________________________________________________

____________________________________________________________________

Has insurance company been notified? __Yes __ No. By phone __ By mail ___ By Phone.

Date and time insurance company was notified? _______________________________

Was the incident documented by use of the following? Photos__ Videotape___

Date and time, fire department, police or emergency personnel was contacted?

______________________ Who was contacted? __________________________

Date and time, someone responded to the situation?__________________________

Follow-up action to be taken by owner or manager ____________________________

____________________________________________________________________

Resident reporting the above incident:________________________________________

Resident’s signature_____________________________________ Date____________

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