| Bodily
Injury Claim Form (PDF)
Form used to submit claim against Escambia County
for alleged bodily injury. (Requires Signature)
Emergency Response Team Incident Report (PDF)
First
Report Of Injury (NOI) (WORD) (REVISED:
17 MAR 2007)
Notice of injury form which is required of all work
related injuries/illnesses. Must be submitted to Risk
Management within 24 hours
General Liability
Claim Form (PDF)
Form used to submit claim against Escambia County
for alleged property damage
General Liability
Report (PDF)
Intradepartmental Report to be completed by Risk Management at time of incident
Medical Authorization
Release (PDF)
Authorization for Escambia County Risk Management
to obtain medical information
on claims alleging bodily information
Notice
To Claimants (PDF)
Information sheet which accompanies claim forms. Provides
claimants with
general information regarding the County's claims
procedures.
Request For Insurance
Coverage (PDF)
Form used to request insurance on newly acquired,
constructed and/or leased property
Request For Temporary
Duty Assistance (PDF)
Form used to request assistance from an employee currently
on temporary duty status
Supervisors
Accident Report (WORD)
Report to be completed by employee's supervisor after
an accident/incident
Temporary Duty Evaluation
Form (PDF)
Form used to evaluate the performance of a temporary
duty employee
Worker's Comp
Fraud Poster (PDF)
Procedures for reporting suspected worker's comp fraud
Reporting
Unsafe Working Conditions (PDF)
Form for reporting unsafe working conditions
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