Incident Report Form
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1Incident Report
(PLEASE PRINT)
In the event an incident occurs during your organization’s activities, it is important to
complete an incident report form immediately. Please complete all sections below and
return to Pullen Insurance Services.
1. Nature
□ BODILY INJURY
□ PROEPRTY DAMAGE
□ OTHER:____________________________
2. Time & Place of Incident
DATE:___________________________ TIME:_________________________ □ AM
□ PM
EVENT:_______________________________________________________________________________
SPORT:____________________________ LOCATION:________________________________________
3. Happened To
NAME:_______________________________________________________________________________
AGE:________________ SEX: □ Male
□ Female PHONE:(_____)____________________________
ADDRESS:____________________________________________________________________________
CITY:__________________________ STATE:___________________ ZIP:_______________________
4. Function
AS: □ PARTICIPANT
□ VOLUNTEER
□ SPECTATOR
□ BYSTANDER
□ OFFICIAL
□ OTHER:_______________________________________________________
5. Apparent Injury or Damage
BODY PART:__________________________________________________________________________
CONDITION: (Laceration, Concussion, Sprain, Fracture, Etc.):___________________________________
□ ON-SITE CARE ONLY, BY (PHYSICIAN) (EMT) (TRAINER) OTHER:_______________________
□ AMBULANCE, TAKEN TO:__________________________ CITY:____________________________
□ FATALITY
□ VEHICLE: MAKE:________________ MODEL:__________________ YEAR:_________________
6. Occasion
WHAT WAS THE SITUATION AND EXACT LOCATION AT THE TIME OF THE
INCIDENT?____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
7. Incident Description
DESCRIBE WHAT HAPPENED:__________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
8. Witness
NAME:________________________________
NAME:____________________________________
ADDRESS:_____________________________
ADDRESS:_________________________________
_______________________________________
__________________________________________
PHONE:(______)________________________
PHONE:(______)____________________________
9. Insured
NAME OF INSURED:___________________________ POLICY #:______________________________
CLUB / TEAM NAME:__________________________ CITY/STATE:___________________________
10. Coach/Official/Team or League Representative
NAME:____________________________________
PHONE:(______)____________________
TITLE:____________________________________
ORGANIZATION:___________________
SIGNATURE:______________________________
DATE:_____________________________
Pullen Insurance Services, Inc. 6300 Ridglea Place Suite 614, Ft. Worth, TX 76116
(817) 738-6100 ; Fax (817) 738-2993
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