ANY FIRE INCIDENT

INCIDENT
ADDRESS PROPERTY AT TIME OF FIRE

AGENCY INVESTIGATOR

CASE NUMBER DATE

CITY

ZIP

MAP PAGE

STRUCTURE
DAY TIME ARRIVED SECURING AGENCY

VEHICLE
CLEARED

WILDLAND
REQ. AGENCY/PERSON

OTHER
PHONE NO.

NOTIFICATION
DATE

SCENE SECURITY AUTHORITY TO ENTER

SCENE SECURED? NO YES

MANNER OF SECURITY OTHER (Describe)

CONSENT EXIGENT VERBAL WRITTEN REL. HUMIDITY WIND DIRECTION

WARRANT ADMIN CRIMINAL GPS WIND SPEED

WEATHER
VISIBILITY TEMPERATURE ELEVATION PRECIPITATION LIGHTNING OTHER

OTHER AGENCY
FIRE DEPT POLICE DEPT FIRST ARRIVING RESPONDER CASE NO. CASE NO. TIME OF CALL TIME OF CALL ASSIGNED UNIT ON SCENE ON SCENE AGENCY TAPPED FIRE CLEARED OBSERVATION REPORT? YES NO SEX AGE DOB ZIP

INVOLVED PARTIES
NO. ADDRESS HOME PHONE NO. ADDRESS HOME PHONE NO. ADDRESS HOME PHONE BUSINESS BUSINESS BUSINESS OWNER RACE CITY CELLULAR RACE CITY CELLULAR RACE CITY CELLULAR SEX AGE DOB ZIP SEX AGE DOB ZIP

[ ] OCCUPANT [ ] OPERATOR [ ] DBA

REPORTING PARTY/PERSON DISCOVERING THE FIRE

INSURANCE
INSURANCE COMPANY ADJUSTER DATE OF POLICY ADDRESS POLICY # POLICY EXPIRED AT TIME OF FIRE? TELEPHONE CLAIM #

YES [ ]
INVOLVED EQUIPMENT
MAKE POWER SOURCE/TYPE MODEL

NO [ ]

LIABILITY ONLY [ ] FULL-COVERAGE [ ]

SERIAL NO. ENERGIZED/POWERED AT TIME OF FIRE? [ ] YES [ ] NO

VEHICLE IDENTIFICATION
COLOR(S) YEAR MAKE MODEL LICENSE VIN

ESTIMATED LOSS - PRELIMINARY CAUSE

STRUCTURE CONTENTS VEHICLE EXPOSURE WILDLAND/OTHER TOTAL LOSS

$ PRELIMINARY CAUSE

ACCIDENTAL

INCENDIARY

NATURAL

UNDETERMINED

**ADDITIONAL INFORMATION ON REVERSE**