Civilian Incident Report

Incident Report

Report Every Accident Promptly
To submit a claim, fill out the form below. You will need to include pictures of the incident.
INCIDENT INFORMATION
Location of Incident*
Date & Time of Incident*
PROPERTY / VEHICLE DAMAGE INFORMATION
Property/Vehicle Owner Name

First NameLast Name
Property/Vehicle Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prop./Vehicle Owner Telephone Number
Please enter a valid phone number.
Prop./Vehicle Owner Email Address
example@example.com
Insurance Company & Policy Number & Phone Number
Brief Description of Damage
Vehicle Year/ Make/ Model
Police Report#
Driver's Name
Driver's Phone Number
Please enter a valid phone number.
Driver's License Number
Driver's Address
Vehicle Tag #
VIN #
Passenger Names
INJURY INFORMATION
Name, Address, & Email Address of Injured
Phone Number
Please enter a valid phone number.
Medical Treatment
Treatment Facility & Telephone Number
Transported by Ambulance

YesNo
Describe injury (Include Body Part)
WITNESSES
Witness #1 Name and Address
Witness Phone Number
Please enter a valid phone number.
Witness Email
example@example.com
Witness #2 Name and Address
Witness #2 Phone Number
Please enter a valid phone number.
Witness #2 Email
example@example.com
IMPORTANT: REPORT MUST BE SIGNED AND INCLUDE PHOTOS
File Upload*

Upload any photos of the incident here
Cancelof
Date of this report*

MonthDayYear
Date
Signature*
Carroll County Government

225 North Center St, Westminster, MD 21157

Report submitted to: Risk Management - 410-386-2082

Cecilia Devilbiss - cdevilbiss@carrollcountymd.gov

Kasie Sumpter - ksumpter@carrollcountymd.gov
Should be Empty:

Incident Report

INCIDENT INFORMATION

PROPERTY / VEHICLE DAMAGE INFORMATION

INJURY INFORMATION

WITNESSES

IMPORTANT: REPORT MUST BE SIGNED AND INCLUDE PHOTOS