Colorado Management & Realty Inc.

 Accident Report

Please you this form to report accidents on the property that occur at your property.  Please be a specific as possible when providing the requested information

Accident: Please provide the following information

Time of Accident                      Date of Accident 

Name of Person Injured:    

Address of Injured Person:

City, State, Zip                  

 Home Phone                            Work Phone  

 Please describe what happened to cause the injury

 Please describe the injuries as reported to you

  Taken to Hospital By Ambulance      Went to Hospital      Went to Doctor     Went Home    Unknown

Witness to Accident   Phone 

                                   Phone 

Please describe efforts, if any, that were done to avoid this hazard (such as shoveling snow at 9am)

Person filling out report:    PLEASE REPORT ANY ACCIDENT IMMEDIATELY TO COLORADO MANAGEMENT & REALTY INC. 
 DO NOT ADMIT ANY LIABILITY FOR ACCIDENT   DO NOT ATTEMPT TO MOVE AN INJURED PERSON
 CALL 911 IF THE PERSON REQUEST ASSISTANCE.