PROPERTY/EQUIPMENT BREAKDOWN REPORT
7225 Parkway Drive
Hanover, Maryland 21076 	1+800-673-8231
TEL: 1+443-561-1700
FAX: 1+443-561-1739
URL: www.lgit.org
	
MEMBER CONTACT	DEPARTMENT CONTACT	
NAME AND ADDRESS
     	BUSINESS PHONE
     	NAME AND ADDRESS
     	BUSINESS PHONE
     	
	WHEN TO CONTACT
     		WHEN TO CONTACT
     	
LOSS INFORMATION	
     	CLAIM	DATE OF ACCIDENT
     	TIME OF ACCIDENT
     	     	AM	PREVIOUSLY REPORTED?	
     	INCIDENT			     	PM	YES	     	
LOCATION OF ACCIDENT (nearest intersection, city, zip)
     	AUTHORITY CONTACTED:
     	VIOLATIONS/CITATIONS
     	
	REPORT#: 
     	CAUSE OF ACCIDENT
     	
DESCRIPTION OF ACCIDENT
     	
MEMBER MOBILE EQUIPMENT	
DESCRIPTION
     	MAKE
     	MODEL
     	SERIAL NUMBER
     	
OWNER'S NAME & 
ADDRESS	     	BUSINESS PHONE
     	
     	(Check if same as Member)			
DRIVER'S NAME
     	PUBLIC WORKS OPERATIONS AT TIME OF OCCURRENCE
     	
STRUCTURE/CONTENTS DAMAGE	NON-MOBILE EQUIPMENT?	YES	     	NO	     		
DESCRIPTION
     	MAKE
     	MODEL
     	SERIAL NUMBER
     	
ADDITONAL INSURANCE POLICIES, WARRANTIES, CONTRACTS, OR OTHER AGREEMENTS
(Include copies with this report)
     	BUSINESS PHONE
     	
	POLICY NUMBER
     	
OWNER, TENENT OR CONTRACTOR IN CONTROL OF PREMISES	     	RESIDENCE PHONE
     	
     	(Check if same as Member)		BUSINESS PHONE
     	
DESCRIBE DAMAGE:	     	
PERSONAL PROPERTY OF AN EMPLOYEE OR VOLUNTEER	
DESCRIBE PROPERTY:	     	MAKE
     	
OWNER’S NAME & ADDRESS	     	RESIDENCE PHONE
     	
DESCRIBE DAMAGE:	     	BUSINESS PHONE
     	
PROPERTY DAMAGE INVESTIGATION	
NAME AND ADDRESS OF NEGLIGENT PARTY
     	RESIDENCE PHONE
     	
	BUSINESS PHONE
     	
NAME AND ADDRESS OF INSURANCE COMPANY
     	POLICY NUMBER
     	BUSINESS PHONE
     	
WITNESSES	
WITNESS 1 NAME AND ADDRESS:	PHONE
     	     	PED	OTHER (Specify)
     	
     		     	OTH VEH		
WITNESS 2 NAME AND ADDRESS:	PHONE
     	     	PED	OTHER (Specify)
     	
     		     	OTH VEH		
IMPORTANT: REPORTS SUBMITTED IN HARD COPY MUST BE SIGNED BY THE SUPERVISOR	
REPORT DATE
     	SUPERVISOR’S SIGNATURE
     	SUPERVISOR’S SIGNATURE