SOMERSET COUNTY JOINT INSURANCE FUND
INCIDENT REPORT

Note: Fields marked with (*) are required.

Member(*)

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Reported By(*)

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Phone(*)

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Email(*)

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Title(*)

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Supervisor Name

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Date Of Report(*)

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Department(*)

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Department Phone(*)

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Optionally send copies of this report to the following email addresses

Email 1

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Email 2

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Email 3

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Incident Type(*)

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Date of Incident(*)

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If Auto, identify driver and vehicle involved:

Driver / Employee

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Year

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Model

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Make

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Vin#

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If Property Claim, identify property damaged

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Location of Loss(*)

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City(*)

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State(*)

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Zip(*)

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Specific Area of Location (if applicable)

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Incident Description(*)

0/500

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Name/Role/Contact Info of Other Parties Involved (1)

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Name/Role/Contact Info of Other Parties Involved (2)

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Name/Role/Contact Info of Other Parties Involved (3)

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Witnesses (1)

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Police Report Filed

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Reporting Officer

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Town

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Phone

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Upload photo or file

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This form is meant for the sole use of SCJIF members to report their claims. Use of this form by the public does not meet the requirements of the NJ Tort Claims Act.

SOMERSET COUNTY JOINT INSURANCE FUND INCIDENT REPORT

SOMERSET COUNTY JOINT INSURANCE FUND
INCIDENT REPORT