DAMAGE CLAIM REPORT
I. Incident Details
(Description of the Report) | Reported by: | [Your Name] |
Date: | May 5, 2055 |
Incident Date: | May 3, 2055 |
(Description of the Report) | Incident Location: | [Your Company Address] |
Claim Number: | DC-2055-0001 |
II. Damaged Property Information
Detail | Information |
|---|
Property/Equipment | Forklift Model XYZ-500, Storage Rack |
Damage Description | The forklift collided with a storage rack. Broken hydraulic system, rack damage, and inventory loss. |
Estimated Value of Damage | $7,500 (forklift repairs: $5,000, rack repair: $1,000, inventory damage: $1,500) |
III. Cause of Damage
Detail | Information |
|---|
Cause of Incident | Operator error, forklift misjudged distance. |
Additional Details | The operator was under pressure to meet a deadline. |
IV. Actions Taken
Detail | Information |
|---|
Immediate Actions Taken | The forklift was taken out of service. Damaged inventory moved to safety. |
Preventive Measures | Safety training on blind spots and forklift maneuvering. Installing additional mirrors and sensors. |
V. Witness Information
Witness Name | Contact Information |
|---|
Etha Lehner | (123) 987-6543, etha@you.mail |
Dell Stokes | (123) 654-3210, dell@you.mail |
VI. Supporting Documentation
Detail | Information |
|---|
Attached Photos/Video | [Attach Photos of Damaged Forklift and Storage Rack] |
Police Report | No, internal incident. |
Insurance Claim Number | INS-2055-5678 |
VII. Claim Resolution Request
Detail | Information |
|---|
Requested Compensation | Repair costs for forklift and storage rack system, and inventory replacement ($7,500). Requesting insurance coverage for damages. |
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