Structure Fire Submission Form
Person Submitting Claim:
Physical Address Required
County and State:
Owner & Occupant Information
Insurance Policy Number:
Privately bill this company / individual if insurance denies payment?
What apparatus was assigned to the incident?
List all unit numbers separated by commas. (ie., Engine 72, Engine 78)
Utility / Brush Trucks:
Any Specialty Equipment?
HazMat Trailer, Rescue Trailer, Light Tower, etc.
Amount of time on the Incident:
Hours and Minutes from Dispatch to Clearing the scene.
Services you provided:
Extinguishment, Rescue, Traffic Control, etc.
Any equipment / gear receive damage while on scene? If so, list name, type, and cost to clean / fix / replace.
Describe the incident what actions you took. Be detailed as possible.
If you have any documents that are related to this incident that you need to include upload them here.