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2. This report is to be used by any citizen involved in a vehicle accident or incident occurring on municipal property which may or may not have required first-aid or hospital treatment, or resulted in the citizen complaining of discomfort or damage to private property as a result of the incident.
4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Home Phone Number*
14. Work Phone Number*
16. Cell Phone Number*
17. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
19. Exact Location of Incident*
20. Describe Incident/Injury*
22. Describe Vehicle/Property Involved*
23. List All Witnesses:*
    (Please include name, address and phone number, if known.)*
25. Was First Aid Given*

    1. Yes
    2. No
26. Type of First-Aid Given (if applicable): (Please include name, address and phone number of those who gave first aid)*
27. Please provide the date and time that any first aid treatment was given:*
    Please provide the date and time that any first aid treatment was given:

    Please provide the date and time that any first aid treatment was given:
29. Was Medical Emergency Treatment Given?*

    1. Yes
    2. No
30. If medical emergency treatment was given, what paramedics/hospital/doctor provided it? (Please give names, address and phone numbers for all treatment providers.)*
32. Please provide the date and time that any medical emergency treatment was given:**
    Please provide the date and time that any medical emergency treatment was given:*

    Please provide the date and time that any medical emergency treatment was given:*
33. Any Other Comments:
35. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
37. Electronic Signature*
39. Please return the completed form by clicking either Submit or Submit and Print below, or by mailing to the Finance Department, Village of Lombard, 255 E. Wilson Ave., Lombard, IL 60148.
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field