DATE

Time

# of Pages (including cover)

ATTENTION

Heidi Rodriguez

FAX #

916.568.0269

COMPANY

DPR Construction

REFERENCE

FROM

REGION

General Liability Report

Property Damage, Theft or Bodily Injury

Incident Reporting Instructions

1. Ensure the safety and security of the individual(s) that were injured or involved, if applicable.

Note: No one except emergency response personnel, owner or OSHA representatives or those associated with or retained by DPR should be allowed on the project site following an incident. Should other individuals require access, prior approval from DPR project management is required. Those individuals require DPR escort at all times.

2. Contact regional safety professional immediately

3. From a safe location -take photos of the accident scene, from all sides of the area and the surrounding area immediately.

4. Contact Heidi Rodriguez at (916) 826-9996 within 2 hours of any incident.

5. Obtain witness names, addresses, phone numbers, and statements.

6. Email the completed form to the following email addresses: [email protected] , [email protected] & [email protected]. FedEx Originals..

Note: The General Liability checklist is available for additional guidance in preparing an incident report in anticipation of litigation.

REQUIRED DOCUMENTS
Completed General Liability report
Witness statements
Photographs of entire area
Copy of master contract
Copy of subcontracts, if subcontractors are involved
Insurance certificates & additional insured endorsements

General Liability Report

PROPERTY DAMAGE, THEFT OR BODILY INJURY

(This report and related documentation is confidential and was prepared in anticipation of future litigation)

Reported by :

Phone :

Date :

Report Prepared for Attorney :

Contacted Regional Safety Manager

Contacted Heidi Rodriguez Cell: 916.826.9996 [email protected]

Contacted Mimi Lee @ Willis –415.955.0171 [email protected]

Post Incident Substance Abuse Screens for all parties, if applicable

INCIDENT DESIGNATION

Incident Only Property Damage Facility/Service Interruption Suspicious claim

Valid Claim Unknown Claim (completely unaware of the incident) Other

Bodily Injury Owner Employee Member of General Public Vendor

#1 –PROJECT INFORMATION

Jobsite Name:

Region/Job Number:

Address/City/State/Zip:

Project Start Date:

Project End Date:

DPR Foreman:

DPR Project Manager:

DPR Superintendent:

DPR Safety:

#2 –INCIDENT INFORMATION

Date of Incident:

Day of Week:

Time of Incident:

Date of Reported:

Reported To:

Reported By:

Involved Address:

Phone:

Damage/Theft/Injury:

Was Employee Taken to a Medical Clinic? :

Yes No

If so, When:

Clinic Address/Phone Number:

List names of persons involved in incident (list additional names on separate piece of paper if necessary):

Name:

Employer:

Phone:

Name:

Employer:

Phone:

Name:

Employer:

Phone:

#3 –ADDITIONAL INFORMATION

Exact Location of Incident:

Architect Name:

Architect Address/Phone:

Subcontractors & Trades Involved:

Name of person/company responsible for maintaining area:

Have any repairs been made? :

Yes No

if yes, what repairs:

Estimated DPR exposure (costs to repair):

#4–INCIDENT DESCRIPTION

NOTE: This does not take the place of any witness statements.Describe in detail the circumstances of the incident(attach diagrams, drawings and/or photos of accident scene). Give a chronological sequence of events. If materials and/or equipment were involved, start before the materials/equipment were brought to the incident scene describing who, what, where, when, how: (PRINT CLEARLY)

Clear signature

NOTE:ATTACH DI AGRAMS,DRAWINGS,PICTURES,ETC.TO CLEARLY DESCRIBE INCIDENT

#5–SIGNATURES

DPR Superintendent:

Clear signature

DPR Project Manager:

Clear signature

DPR Safety:

Clear signature