PLEASE READ INSTRUCTIONS PRIOR TO COMPLETING INCIDENT REPORT FORM.
These instructions are to assist you in filling out the Incident Report Form located in the event of an injury. Above all else, the form should be filled out as completely and accurately as possible. Completing this form shortly after the incident helps assure that all applicable information has been obtained. However, please remember that caring for the injured person is of primary concern.
If a waiver/release was signed by the injured person, or on his/her behalf, please attach a copy of the signed waiver/release to the Incident Report Form.
In the event that the injury involved the use of any equipment, you should inspect and document that equipment. Often, a picture of the equipment along with a description of its condition at the time of the injury will suffice. If you perceive that any problem exists with the equipment, it should be secured until otherwise instructed.
At this stage, it is important to gather all relevant information possible concerning the accident. No one from the business should discuss any opinion they might have as to the cause. It is important that you be factual. Opinions will be rendered at a later date once all relevant information has been reviewed and appropriately analyzed.
Additional considerations are as follows:
Print and complete the Incident Report Form.Once completed, please forward the Incident Report Form, waiver/release, witness statements, pictures and “Claim Notification” to the person identified in your insurance policy, or to firstname.lastname@example.org.
Please feel free to contact Perry Wells at 252-261-1903 x238, or via email at email@example.com.