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2. CITIZEN INCIDENT REPORT

   City of Fort Pierce - Risk Management 

   To be completed by reporting citizen

   100 N. US Highway 1, Fort Pierce, FL 34950 | Direct: (772) 467-3070

   Please include receipts, images, and any other documents related to your claim

4. First Name*
5. Last Name*
6. Phone Number*
8. Email Address*
9. Date of Birth MM/DD/YYYY
11. Driver's License Number *
12. State Drivers License Was Issued
14. If Minor, List Guardian's Name
16. Street Address*
18. Street Address 2
20. City*
21. State*
22. Zip Code*
24. POLICE REPORTING
26. Were Police Called to the Scene? *

    1. Yes
    2. No
27. Police Department Called
28. Police Report Number (Required if a report was taken)
30. INJURY REPORTING
32. Injured?*

    1. Yes
    2. No
33. Medical Treatment Required? *

    1. Yes
    2. No
34. Ambulance Required?*

    1. Yes
    2. No
35. Can you provide video of the incident? *

    1. Yes
    2. No
37. Total amount $ of medical bills
38. Body part injured (i.e. left arm) *
39. Cause of damage
41. Can you provide video of the incident?

    1. Yes
    2. No
42. Witness's Name
43. Witness's Telephone Number
45. PROPERTY DAMAGE REPORTING
47. What was damaged?*
48. Vehicle ID Number (VIN)
49. Vehicle Tag Number
51. Vehicle Make
52. Vehicle Model
53. Vehicle Year
55. Estimated amount $ of damage
56. If not vehicle. type of damage
58. Witness's Name
59. Witness's Telephone Number
61. LOCATION OF INCIDENT
63. Address (or what road and cross street) *
65. In front or near what landmark
66. What city facility or near what city buidling
68. Cause of damage*
70. Weather Conditions: *

    1. Clear
    2. Foggy
    3. Rainy
    4. Windy
    5. Other
71. Other:
73. Detailed description of what occurred, damage incurred, and cause of damage*
75. Please upload any receipts, images and other documents related to your claim.
77. FRAUD ACKNOWLEDGEMENT

79. “Pursuant to s. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured, prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleading information concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084, Florida Statutes.” 

81. Date
82. Signature

84. If you choose to provide information through any form on this site, unless specifically exempted by Florida Statutes, such information is a public record under Florida's Government in the Sunshine Laws and available for public inspection upon demand.

Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field