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2. This form is to be used when submitting supplements/documents regarding any work related accident or a work related injury.
4. First Name of Reporting Party*
5. Last Name of Reporting Party*
7. Date of Incident:*
   Date of Incident:

   Date of Incident:
8. Type of Incident: *
   -- Select One --Motor Vehicle or Equipment AccidentEmployee Work-Related InjuryMotor Vehicle or Equipment Accident & Employee Work-Related InjuryEmployee Work-Related Incident (No Injury)Act of Nature - Weather RelatedVandalism - Unknown
9. Date of Initial Report Submitted:*
   Date of Initial Report Submitted:

   Date of Initial Report Submitted:
10. Department:*
    -- Select One --Administrative ServicesDev ServicesFinanceMunicipal CourtPolice Public WorksTown Manager/Town Secretary
12. First Name of Employee Involved:*

    If  not employee related - list  "None"

13. Last Name of Employee Involved:*

    If  not employee related - list  "None"

14. Title of Employee:*

    If  not employee related - list  "None"

16. Image and Picture Upload

    You can upload multiple files at once, with the size limit being 20MB.   Anything larger can be reduced in size via PDF and uploaded.

18. Image/File Upload:*
19. Image/File Upload:
20. Image/File Upload:
21. Image/File Upload:
23. Image/File Upload:
24. Image/FileUpload:
25. Image/File Upload:
26. Image/File Upload:
28. Image/File Upload:
29. Image/File Upload:
30. Image/File Upload:
31. Image/File Upload:
33. Image/File Upload:
34. Image/File Upload:
35. Image/File Upload:
36. Image/File Upload:
38. Image/File Upload:
39. Image/File Upload:
40. Image/File Upload:
41. Image/File Upload:
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field