City of De Pere

dpclerk@deperewi.gov

335 S Broadway

920-339-4050

INCIDENT REPORT FORM

Any vehicle accident or incident of property damage should be reported within 48 hours. If at all possible, please take photos of the damage to include with this report.

What type of incident are you reporting?

Damage to City property

Vehicle accident

Supporting information for a liability claim

Supporting information for an existing report

Lost or stolen property

Date of incident? (if unsure, use date discovered)

Time of incident? (if unsure, use date discovered)

Location?

Was a police report filed for this incident?

Yes

Unknown

Police Department Report # or Tag #

Cause of damage?

Vehicle Accident (driver known)

Hit and Run

Other - describe below

Please describe what caused the damage

Type of Property

Brick Planter

Light Pole

Park Damage

Street Sign(s)

Trees

Hydrant

Traffic Signal

Other - describe below

Please describe the property that was damaged

Please provide details about the damage incurred

Please provide a brief description of the circumstances of the accident

City vehicle information (make/model/year)

VIN# or City vehicle ID#, if known

Please describe the damage to the vehicle

Driver information (include name, address, and phone number)

Were there any passengers in the vehicle?

Yes

Please provide name(s) and phone number(s) for any passengers

Did the accident involve another vehicle?

Yes

Please provide the name and contact information of the other driver

Other vehicle information (make/model/year)

Please describe the damage to the other vehicle

Estimated cost of damages

Please attach estimate(s) or invoice(s) here. If you do not have them yet, make sure to forward them to the Clerk's office as soon as possible in order to avoid unnecessary delays in processing the claim

Click Here to Upload

Which account number should be used for claim reimbursement?

Upload photo(s) of the damage here

Click Here to Upload

Name of employee reporting the incident

Department

Please provide any additional remarks you feel would be helpful to us in processing this report

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