Alpha Gamma Rho

When an incident arises at the chapter causing any bodily injury or property damage to
any person, the following information must be obtained immediately. This report is
being completed for submission to our attorney, so please be thorough.
If the bodily injury is of a serious nature, please call Executive Director Phil Josephson at 816-891-9200 ext. 18, or fax to 816-891-9401.

Date of Incident required

MMDDYYYY

Chapter Name required

Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Noble Ruler required

Noble Ruler Telephone # required

(###)#######

Noble Ruler Cell Phone # required

(###)#######

Noble Ruler Email Address required

Adviser Name required

Advisor Telephone # required

(###)#######

Adviser Cell Phone # required

(###)#######

Adviser Email Address required

Adviser Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Alumni Corporation President required

Alumni Corporation President Telephone # required

(###)#######

Alumni Corporation President Cell Phone # required

(###)#######

Alumni Corporation President Email Address required

Alumni Corporation President Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Name of Injured Party required

Telephone # of Injured Party required

(###)#######

Witnesses

Telephone # of Witnesses

Description of what happened (what, when, where, how, how much)

Incident/Claim Reporting Form