2. General incident report form

4. Type of incident:*
   -- Select One --Vehicle Crash (while being driven or occupied)Vehicle Parked (occupied or unoccupied)Equipment Damage (only use when no vehicles are involved)Utility DamageGeneral Incident (with or without citizen involvement)Other
6. First Name*
7. Last Name*
9. Employee Cell Phone Number:*
10. Employee number:*
11. Date and time of incident:*
    Date and time of incident:

    Date and time of incident:
13. District/Department/Division:*
    -- Select One --District 1-Milford GarageDistrict 2-Davisburg GarageDistrict 3-Lake Orion GarageDistrict 4-Waterford GarageDistrict 4S-Southfieild GarageDistrict 4T-Troy GarageDistrict 5-StockroomDistrict 6-Fleet ManagementDistrict 7-Sign ShopDistrict 8-ElectricalDistrict 9-Building MaintenanceAll other Departments or Divisions
14. RCOC Vehicle or Equipment Number: *
15. RCOC License Plate Number: *
17. Name of street where incident occurred on:*
18. Name of nearest cross street where incident occurred:
19. City/Village or Township of incident:*
    -- Select One --Addison TownshipBerkleyBeverly Hills (Village)BirminghamBingham Farms (Village)Bloomfield HillsBloomfield TownshipBrandon TownshipClarkston (Village)ClawsonDavisburg (Springfield Township)FarmingtonFarmington HillsFenton Ferndale Franklin (Village)Groveland TownshipHazel Park Highland TownshipHolly TownshipHolly (Village)Huntington WoodsIndependence TownshipLake Orion (Village)Leonard (Village)Lyon TownshipKeego HarborLake AngelusLathrup VillageMadison HeightsMilford TownshipMilford (Village)NorthvilleNorthville TownshipNovi Novi TownshipOak ParkOakland TownshipOrchard Lake Village (City of)Orion TownshipOrtonville (Village)Oxford TownshipOxford VillagePleasant RidgePontiacRochester Rochester HillsRose TownshipRoyal Oak Royal Oak TownshipSouth LyonSouthfield Southfield TownshipSpringfield Township (Davisburg)Sylvan Lake TroyWalled LakeWaterford TownshipWest Bloomfield TownshipWixomWhite Lake TownshipOther location
21. Were any citations issued?*
    -- Select One --YesNoUnknownNot applicable
22. If citations were issued, who were they issued too?*
    -- Select One --RCOCOther driver(s)UnknownNot Applicable
24. Summary of exactly what occurred:*
26. Describe any other equipment or vehicles involved:*
28. Describe damage that occurred: *
30. What purpose was the activity being performed:*
32. Witness(es), passenger(s) or involved citizen(s) name(s):*
34. Name of any responding Police Department:*
35. Name of any responding Fire Department:*
36. Name of any responding Ambulance Company:*
40. Utility Facility Name:*
    -- Select One --AmeritechCity/Village/Township DPWComcastConsumers EnergyDetroit Water and SewerGreat Lakes Water AuthorityGTEVerizonWOWNot Applicable
41. Was the utility notified:*
    -- Select One --YesNoNot Applicable
42. If utility was notified, provide the date and time:
    If utility was notified, provide the date and time:

    If utility was notified, provide the date and time:
44. Was Miss Digg called?*
    -- Select One --YesNoNot Applicable
45. If Miss Digg was called, provide the date:
46. Provide the Miss Digg ticket number:
48. Were utilities found prior to any excavations being done?*
    -- Select One --YesNoUnknownNot Applicable
49. Attach a copy of the Crew Card if applicable:
51. Are there any circumstances why a utility damage claim should be approved or disputed?*
    -- Select One --YesNoNot Applicable
52. List any reasons why:*
56. Download any additional items (photographs or documents):
62. Electronic Signature Agreement

    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.

    1. I agree.
64. Electronic Signature*
65. Date*
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field