Dog Bite Incident Form

INCIDENT INFORMATION
Exact Date of Accident:_______________  Time:________________  City:______________________

Exact Location:______________________________________________________________________

DOG OWNER’S INFORMATION

Name:________________________________________________Phone No.:____________________ 

Address:___________________________________________________________________________

Dog’s Breed:__________________________________________________  Color:________________

Dog Owner’s Home Insurance:__________________________________________________________

Phone No.:________________________________  Adjuster Name:____________________________

Address:___________________________________________________________________________

Claim/Policy No.:____________________________________________________________________

MY INFORMATION

Witness ‘s Name #1:_________________________________Phone No.:________________________

Address:___________________________________________________________________________

Witness ‘s Name #2:_________________________________Phone No.:________________________

Address:___________________________________________________________________________

Animal Control Called?  Yes ( )    No ( )

Department:_________________________________________Phone No.:______________________

Report No.:__________________ Animal Control Officer’s Name:_____________________________