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City of Concord Risk Management

riskmanagement@concordnc.gov

35 Cabarrus Ave W.
Concord, NC 28025

704-920-5109

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This form must be signed and submitted within
24 hours
of reported incident. (Please be sure to click "
Finalize and Submit
" after signing.)

Supporting documents (Photos, Doctors Note, Police Report) must be emailed to
riskmanagement@concordnc.gov
after submiting this form


All signatures on this report verifies that the statements made are true and accurate to the best of the signers knowledge

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12/21/2024Click to Sign
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12/21/2024
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12/21/2024
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12/21/2024

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