Texas Department of Insurance
State Fire Marshal’s Office, Mail Code 112-FM
333 Guadalupe • P. O. Box 149221, Austin, Texas 78714-9221
512-305-7900 • 512-305-7910 fax • www.tdi.state.tx.us
e-mail   fire.marshal@tdi.state.tx.us	

FIREWORKS INCIDENT REPORT FORM

28TAC §34.819(d) requires licensees and permittees to report in writing any unauthorized incident of explosion or fire involving fireworks to the state fire marshal within 10 days after the occurrence.  Incidents resulting in injury or death shall be reported immediately.  In addition, 28TAC §34.819(c) requires the loss, theft, or unlawful removal of black powder and Fireworks 1.3G shall be reported immediately to the State Fire Marshal.  This form may be mailed, faxed or e-mailed to the State Fire Marshal’s Office.

PLEASE PRINT OR TYPE

LICENSEE OR PERMITTEE REPORTING THE INCIDENT	
Name (Last, First)	Representing: (Firm name or Self)	Phone number	

	
	
Mailing address (street or PO Box)	City & State & Zip Code	Permit or License Number	

	

INCIDENT INFORMATION	
Date and time of incident	Name of location	

	
Location address (street & city)	

Type of incident	
 Theft	 Fire	 Explosion	 Other  _________________________	
Name(s) and address of any injured person(s):	
	
This occurred at or during:	
 Fireworks 1.3 Public Display   Flame Effects show   Pyrotechnics before a proximate audience  
 Fireworks sales location   A fireworks storage facility   Other _____________________________	

BRIEF DESCRIPTION OF THE INCIDENT (Attach additional sheets if necessary)	

	

	

	

By submission of this form to the State Fire Marshal’s Office, it is implied that the information herein is true and correct to the best of my knowledge.

Signature of licensee or permittee:  		Date:  	

NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES

With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you.  Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information.  However, TDI may withhold information for reasons other than to protect your right to privacy.  Under section 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect.  For more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please contact the Agency Counsel Section of TDI’s Legal & Compliance Division at (512) 475-1757 or visit the Corrections Procedure section of TDI’s web page at www.tdi.state.tx.us.