Board for Volunteer Fire Fighters and Reserve Officers

ACCIDENT REPORT CARD
To send electronically, please fill out the form below and click the send button.

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