6a62aa2bb518e 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 Registered and report? 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) 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
