PD Case #:
CITY OF CHICO REPORT OF ACCIDENT, THEFT, DAMAGE OR LOSS INVOLVING CITY PROPERTY
SECTION I. DATE AND PERSONS INVOLVED
Type of Report: ☐ Accident ☐ Theft ☐ Damage ☐ Loss	Date of Incident/Loss:	Time:
Report Category: ☐ City Property Damage ☐ Vehicle Accident ☐ City Tree ☐ Personal Injury ☐ City Keys/Uniform/Gear ☐ Police Action Property Damage ☐ Other:
Persons Involved	Name:	Address:	Phone:
Name:	Address:	Phone:
Witnesses	Name:	Address:	Phone:
Name:	Address:	Phone:
SECTION II. DESCRIPTION
Location of Incident:	Injuries Sustained: ☐ No ☐ Yes
Detailed Description of Incident, Damage, and Injuries:
SECTION III. VEHICLE INFORMATION
VEHICLE NO. ONE	Driver Name:	Address:	Phone:
Driver License #:	Driver License State:	Vehicle Make/Model:	Vehicle Year:	Vehicle License Plate #:
Registered Owner Name:	Registered Owner Address:
Insurance Company:	Insurance Policy #:
VEHICLE NO. TWO	Driver Name:	Address:	Phone:
Driver License #:	Driver License State:	Vehicle Make/Model:	Vehicle Year:	Vehicle License Plate #:
Registered Owner Name:	Registered Owner Address:
Insurance Company:	Insurance Policy #:
SECTION IV. REPORTING AND ACTION INFORMATION
Report Completed By:	Job Title:	Department:	Date:
Action Taken:
Action Taken By:	Job Title:	Date:	Supervisor Signature: