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ACCIDENT REPORT CARD
To send electronically, please fill out the form below and click the send button.
acrobat download You may also download an Accident Report Card and mail it to us. The document is in PDF format and you will need Adobe Acrobat Reader for viewing and printing.
Name of Department
Dear Chief or Sheriff:
In case of injury, immediately complete the on-line or mail in form. This will comply with the 90-day reporting requirement of the Volunteer Fire Fighters' and Reserve Officers' Relief and Pension Act, but a regular report MUST be filed before any claims can be paid. Please make sure to record the name of the Injured Member, Date of Accident and Date ARP was filed.

Sincerely,
Board for Volunteer Fire Fighters and Reserve Officers
Name of Injured Member
Today's date
Birth date
Accident Date
Nature of Injury
Time Loss from Work No Yes
Estimate Time Loss Days
Hospitalized? No Yes
How Did Injury Happen?
Check Box to Receive Additional Cards
Check Box if Accident reported to Chief
Doctor's Name
Chief's or Sheriff's Name
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