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Get GA DOAS/RMS GL Report Form 2010-2024

STATE OF GEORGIA General Liability Incident Report Form If a non-state employee is injured or property of others is damaged or alleged as a result of the State s operations whether negligent or not report the claim directly to DOAS / Risk Management Services by calling 404-656-3237 or Email to risk. management doas. ga.gov or Fax to 404-657-1188. Keep your answers brief and to the point. Do not use this form for Auto Liability Claims Time is of the essence. Accident Information - General Liability State Agency involved Date of the incident Incident time Incident location City and County Description of the incident Police authorities contacted If yes Accident Report Number Claimant Information Name address of the Claimant Home Telephone No. Work Telephone No. Injured party date of birth Social Security No. Injury Information Brief description of the claimant s injury Fatality Yes What initial treatment was given Was hospital treatment needed No By whom Which hospital Witness Information Were there any witnesses If so their name address phone no Property Damage to Others Information Claimant s property involved Where is the property located now Damage to Claimant s property Repair estimate Comments Your Name Phone Number DOAS/RMS GL Report Form 10/07/2010. management doas. ga*gov or Fax to 404-657-1188. Keep your answers brief and to the point* Do not use this form for Auto Liability Claims Time is of the essence. Do not delay reporting the claim because you do not have all the information regarding the accident. Any additional information can be provided at a later date. Use multiple sheets for more than one Claimant. management doas. ga*gov or Fax to 404-657-1188. Keep your answers brief and to the point* Do not use this form for Auto Liability Claims Time is of the essence. Do not delay reporting the claim because you do not have all the information regarding the accident. Do not delay reporting the claim because you do not have all the information regarding the accident. Any additional information can be provided at a later date. Use multiple sheets for more than one Claimant. management doas. ga*gov or Fax to 404-657-1188. Keep your answers brief and to the point* Do not use this form for Auto Liability Claims Time is of the essence. Do not delay reporting the claim because you do not have all the information regarding the accident. Any additional information can be provided at a later date. Use multiple sheets for more than one Claimant. .

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