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This Form is for Documenting Damage and/or Accidents. The form will be sent to Department Head, Risk Management & Fleet Division
If Yes, Fleet Service Request Required. (Clicking Yes will display link)
Complete Service Request before proceeding further. Number required below on this form.
The employee MUST fill out a Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure Form (Clicking Yes will display link)
Any and all property damage must be listed to include an Employee's private property if any.
Enter City Vehicle Number
Year Make Model Color
State / Number
Name / Phone Number
State Issued DL Number
Be specific/include the name of the person administering
From Fleet Service Request submission
Must be filled out by the Supervisor
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
This field is not part of the form submission.
* indicates a required field