STATE SELF-INSURANCE CLAIM REPORT FORM For State Agencies Use Only

STATE SELF-INSURANCE CLAIM REPORT FORM
For State Agencies Use Only

Lower of price agreement or 3 vendor estimates or bids.
Cost to buy a new item of same/like kind of damaged item.
Not worth repairing? See "Total Loss" on reverse side of this form.
$2,500 or $1,000. See "Deductible" on reverse side of this form

Agency

Agency Number

Agency Address

City

State

Zip

State Employee Involved

Daytime Phone

Date of Incident

	a.m.
	p.m.
	Time

Building Name

Incident Location: Street Address & City OR Hwy No., Milepost, & City, OR Intersection & City

Brief Summary of facts as reported by:

	Claimant
	State
	Other

Driver of state vehicle was a:

	State Employee
	Volunteer
	Student
	Contractor
	Other (Describe)

Did police investigate?

	Yes
	No

If yes:

	State
	County
	Local

Report Number

Witness Name(s)

Address

Daytime Phone(s)

Employee? ( Y / N )