Form Center

2. Williamson County School System
   Student Treatment Form
   
   Williamson County Risk Management
3. Claim #
   Risk Management Use Only
5. 1320 West Main Street, Suite 108
   Franklin, Tennessee 37064
   Telephone: (615) 790-5466 Fax: (615) 591-8516
   Email: wayne.franklin@williamsoncounty-tn.gov
7. Loss Information
8. Department/School*
9. Date of Loss/Time of Day *
11. Loss Location (incl. city/state)*
13. Authority Contacted:
14. Report #
16. Loss Details
    (Use separate sheet if necessary for complete explanation)
18. (1) Type of Loss:

    1. Fire
    2. Theft
    3. Lightning

    1. Hail
    2. Flood
    3. Wind
19. Other
21. Description of Loss and/or Damage (Use separate sheet if necessary for complete explanation)
23. Make/Model, Serial/ID #, $ Estimate of Loss
25. (2) Type of Loss:

    1. Fire
    2. Theft
    3. Lightning

    1. Hail
    2. Flood
    3. Wind
26. Other
28. Description of Loss and/or Damage (Use separate sheet if necessary for complete explanation)
30. Make/Model, Serial/ID #, $ Estimate of Loss
32. (3) Type of Loss:

    1. Fire
    2. Theft
    3. Lightning

    1. Hail
    2. Flood
    3. Wind
33. Other
35. Description of Loss and/or Damage (Use separate sheet if necessary for complete explanation)
37. Make/Model, Serial/ID #, $ Estimate of Loss
39. (4) Type of Loss:

    1. Fire
    2. Theft
    3. Lightning

    1. Hail
    2. Flood
    3. Wind
40. Other
42. Description of Loss and/or Damage (Use separate sheet if necessary for complete explanation)
44. Make/Model, Serial/ID #, $ Estimate of Loss
46. Injured
47. Name
48. Address
50. City / State / Zipcode
52. Transported to Hospital:

    1. Yes
    2. No
53. Hospital Name:
54. Refused Treatment::

    1. Yes
    2. No
56. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against Williamson County Government or its Excess Insurance Carrier, submits an application or files a claim report which contains a false or deceptive statement is guilty of insurance fraud and will be prosecuted to the fullest extent of the law.
58. Report Date:*
59. 20*
60. Reported By:*
Leave This Blank:


62. Submit

* indicates a required field