2. Fire Reports
   - Must have Photo ID - Be Owner or Occupant - Or Insurance Agent
4. EMS Reports
   - Must have Photo ID - Be the Patient - Or have, in writing, permission from patient
8. Requestor Information
10. Date*
    Date
12. First Name*
14. Last Name*
16. Address*
18. Email*
20. Phone Number
24. Incident Information
26. Date of Incident*
    Date of Incident
28. Location of Incident*
30. Type of Incident*

    1. Fire
    2. EMS
    3. Other
32. If other please specify
34. Any other information here
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field