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Williamson County Government Risk Management Division Property Loss Notice

  1. Williamson County School System
    Student Treatment Form

    Williamson County Risk Management

  2. Risk Management Use Only

  3. 1320 West Main Street, Suite 108
    Franklin, Tennessee 37064
    Telephone: (615) 790-5466 Fax: (615) 591-8516
    Email: wayne.franklin@williamsoncounty-tn.gov

  4. Loss Information

  5. Loss Details

    (Use separate sheet if necessary for complete explanation)

  6. (1) Type of Loss:

  7. (2) Type of Loss:

  8. (3) Type of Loss:

  9. (4) Type of Loss:

  10. Injured

  11. Transported to Hospital:

  12. Refused Treatment::

  13. 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.

  14. Leave This Blank: