Damage Claim Report
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. |
