Founder Shield

carl@foundershield.com

119 w 24th, 4th Floor, New York, NY, 10011, US

646-854-1058

Founder Shield Incident Report Form

What is the legal name of your entity?

Phone Number

Where did the incident occur?

What time of day did the incident occur?

To whom at Founder Shield did you report this incident?

Did you file a police report?

Yes

Please enter a description of the incident and the nature of any injuries sustained:

Name, address, and Phone Number of any injured person(s):

Please list all contributing factors that may have played a role in causing this incident:

Was first-aid administered at the scene of the incident?

Yes

How was the injured person removed from the scene:

Did any property damage occur from this incident?

Yes

Please List the names of the witnesses to the incident:

Please upload any pictures of the incident or damaged goods:

Click Here to Upload

Signature of person making report on behalf of insured:

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.