67ecb39821719 Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.INCIDENT REPORT Site: Premier Storage 2, 3265 S Ave 3 3/4 E, Yuma, AZ 85365 Report Date: Reporting Party InformationReport made by: *FirstLastEmail Address *Phone Number *What is your relationship with us? *Tenant/OwnerGuest/VisitorVendorOtherUnit # *Name of tenant/owner you were visiting? *What company do your work for? *What is you purpose of accessing our facility? *What is your involvement in the incident? *Witness to an incident (Witness)I caused an incident (Responsible party)An incident happened to me (Victim)THIS INCIDENT INVOLVES: *Damage to or loss of Premier Storage 2 propertyDamage to or loss of tenant/owner propertyBodily injury to any personA motor vehicle (incident caused by or caused to a vehicle)Someone apparently at fault for the incidentOther witnesses to the incident (Not myself)A police report was filedSelect all that applyIncident Date / Time *DateTime A. Bodily Injury A. Injury is to *Company EmployeeTenantOtherA. Person Injured *A. PhoneA. Nature of injury (cut, bruise, etc.) *A. Part of Body Injured *A. Injury Required *First Aid911 / Emergency servicesOtherA. Activity that led to injury *A. Where did incident take place? * A.1 Employee Injury A.1 Last date worked after injuryA.1 Has employee returned to work? *YesNoA.1 Additional Details B. Facility Damage or Theft B. Property damaged or stolen *Front GatesEntry/Exit keypadsPerimeter FenceBuildingOtherCheck all that apply.B. Location Details *B. Cause of Damage *Caused by someone / accidentVandalismTheftWater DamageStorm Damage C. Tenant Property Damage or Theft C. Incident Unit # *C. Tenant Name *C. Who Discovered Issue? *C. Cause of Tenant Damage *Caused by someone / accidentVandalismTheftWater DamageStorm DamageFire DamageUnknownPestsC. Did you provide coverage for your belongings per your lease agreement? (insurance is not provided by us) *YesNoNot sure D. Responsible Party D. Name of person responsibleD. Phone for Responsible PartyD. Additional details of Responsible party(Address, description, unit number, other identifying information) our A. your E. Witness E. Witness Name & Phone number *(If unknown, provide other details such as unit number, description, etc.) F. Motor Vehicle Information F. Vehicle Description (Year / Make / Model / Color) *F. Insurance Information *Yes, full coverage insuranceYes, liability insuranceNo insuranceUnknownF. Plate # *F. Policy HolderF. State Registered *F. Insurance CompanyF. Additional info (Rental car, Rental company, Business vehicle, etc)F. Policy NumberF. Phone Number G. Police Report G. Who filed the police report? *G. Report # *G. Reporting Officer *G. Police Report Date / Time *DateTimeG. Was a copy obtained? *YesNo H. Detailed Description of Incident Describe what happened as clearly as you can. Try to answer the questions: Who? Did what? Where? When? How? *Photos, Videos, or Diagrams Click or drag files to this area to upload. You can upload up to 10 files. Photos of the incident scene and damaged goods uploadedCertification and Authorization: *I hereby certify that the statements I have made in this report are true, complete, and accurate to the best of my knowledge. I understand that providing false information or omitting relevant details may result in the termination of my storage agreement, the loss of access to the facility, and/or potential legal action. By signing below, I acknowledge that this report is a truthful account of the incident as I have described it. Signature Date: Signature * Clear Signature Submit
