Incident Report Form
Today's Date
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Month
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Day
Year
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Individual Reporting Claim Name
*
First Name
Last Name
Phone Number
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Area Code
Phone Number
Email
*
example@example.com
Incident Date and Time
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Month
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Day
Year
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Location
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Description of Incident
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Was this reported to the an E-Z Bel Representative?
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Yes
No
If yes, please provide the name of the person to whom the incident was reported
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Was there damage to property?
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Yes
No
If yes, please provide a description of the damage
*
Please provide any photos or documents related to the incident
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