Customer Accident/incident Report Form
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1CUSTOMER ACCIDENT/INCIDENT REPORT
Policy #: _____________________________
Date of Report: ________
Store Name:________________________________________________
Address: _______________________________________Phone Number_______________________
GENERAL INFORMATION
Date of Accident: ______________
Exact Time of Accident: ______ A.M./P.M.
Name of Manager on duty at time of accident: _________________________________________
Name of Store Employee who completed this report: ____________________________________
1. Did you witness accident/incident? Yes
No
2. If not, who informed you of the accident? ____________________________________
Outside weather conditions: (circle all that apply): Clear, Cloudy, Raining, Snowing, Windy, Light, Dark
Other__________________________________________________________________________
Exact location of accident/incident at store __________________________________________________
Description of Accident or Incident: _______________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Name, address, phone and/or website of manufacturer or supplier of product, equipment, merchandise
involved: __________________________________________________________________________
*** PLEASE SAVE THE PRODUCT OR EQUIPMENT FOR FURTHER INVESTIGATION ***
Did you inspect location immediately after accident/incident? Yes
No
Exact Time of inspection: ____________
Number of photographs taken of location: _________
Was location clean? Yes
No
Dry? Yes
No
Any signs posted?_____________________________________________________________________
When was the last time the area was cleaned? __________ By whom? __________________________
When was the last time the area was checked? _________ By whom? __________________________
Describe lighting conditions: _____________________________________________________________
INJURED PERSON INFORMATION
Name of person injured: ________________________________________________________________
Home Address: _______________________________________________________________________
Home Phone #:_______________________________ Age or Date of Birth: ______________________
Name of Employer: __________________________________ SS # ____________________________
Occupation:__________________________________________________________________________
Work Phone #:__________________________
Was injured person wearing glasses? _____________________________________________________
Type of footwear injured person was wearing: _______________________________________________
Describe Injury: _______________________________________________________________________
Describe medical care at scene & name of doctor, hospital or clinic:
____________________________________________________________________________________
____________________________________________________________________________________
Where taken and how? _________________________________________________________________
Name of injured person’s companion, if any: ________________________________________________
Address: ____________________________________________________________________________
Home Phone #: _______________________________________________________________________
Witnesses, if any:
Name: ________________________________ Name: _____________________________________
Address: ______________________________ Address: ___________________________________
Phone #: ______________________________ Phone #: ___________________________________
Revised 09/28/06
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