Incident/Claim Reporting Form

When an incident arises at the chapter causing bodily injury or property damage to any person, the following information must be obtained immediately. This report is being prepared for submission to an Alpha Phi Alpha Fraternity, Inc. General Counsel so please be thorough. Do not withhold reporting an incident to obtain all required information. Because timeliness is of the essence, report it immediately and send a copy within 24 hours to the Corporate Headquarters of Alpha Phi Alpha Fraternity, Inc., 2313 St. Paul Street, Baltimore, MD 21218- 5234. If the bodily injury is of a serious nature, a telephone call should also be made.

Chapter Name
Date of Incident
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Chapter Phone
Chapter President
First Last
Chapter Advisor
First Last
CA Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
CA Phone
Injured Party Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Injured Party Phone
House Corp President
First Last
House Corp Pres Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
House Corp Pres Phone
Witness 1 Name
First Last
Witness 1 Phone
Witness 2 Name
First Last
Witness 2 Phone
Witness 3 Name
First Last
Witness 3 Phone
Additional Witness Names and Numbers
Did the Incident Happen off Premises?
- Yes
- No
Owner's Name
First Last
Owner's Phone
Police Investigation?
- Yes
- No
Name of Agency
Case Number
Description of injury & where was injured party taken
Description of What Happened
Additional Information
Form Completed By
First Last
Phone
Email Address

Incident/Claim Reporting Form

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