Risk Management Division

Forms and Reports

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: JUN 2008)
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