• NOTE YOU SHOULD NOT MAKE ANY ADMISSION OF LIABILITY OFFER PROMISE OR PAYMENT

  • THIS REPORT IS NOT TO BE SEEN BY OR COMPLETED BY A THIRD PARTY

  • COMPLETE FOR ALL INCIDENTS

  • Site Code

  • Incident Date and Time

  • Site Address

  • Site Manager or Supervisor

  • Name of Person Completing Report

  • Title / Position

  • Incident Type:

  • Other

  • How was the incident reported

  • Date Report Completed

INCIDENT DETAILS - Names, addresses and contact details of all persons involved (including witnesses)

Person Reporting Incident

  • Name

  • Address

  • Home Phone

  • Work Phone

  • Mobile

  • Email

OWNER / DRIVER / INJURED PERSON ( if different from above)

  • Name

  • Address

  • Home phone

  • Work phone

  • Mobile

  • Email

Witness 1

  • Name

  • Address

  • Home phone

  • Work phone

  • Mobile

  • Email

Witness 2

  • Name

  • Address

  • Home phone

  • Work phone

  • Mobile

  • Email

Witness 3

  • Name

  • Address

  • Home Phone

  • Work Phone

  • Mobile

  • Email

COMPLETE FOR DAMAGE TO PROPERTY (INCLUDING VEHICLES)

  • Where did the incident occur?

  • Add a photo showing the location

  • On what date and at what time did the incident occur?

  • Was an attendant or valet in charge of, or driving the vehicle?

  • If Yes, Attendants Name:

  • How did the incident occur ? (Full description of circumstances and details of what occurred are required)

  • Nature and extent of damage ? (Full description of damage and location on vehicle / property is required)

  • Take a photo of the damage

  • Take a photo of the damage

  • Take a photo of the damage

  • Take a photo of the damage

  • Take a photo of the damage

  • Take a photo of the damage

  • Vehicle Details - Registration

  • Vehicle details - make

  • Vehicle Details - model

  • Was any other action taken ? (eg lift repaired or checked, boom gate repaired or checked)

  • Has any claim been made on you either verbally or in writing ( if yes please state details of claim or attach a copy)

  • Is there any other relevant documentation available ? ( eg photos / CCTV of the area incident occurred) If so provide full details below and attach to this document

  • Ensure CCTV footage has been isolated and is available

  • Report Issued to (name and title)

  • Provide additional photos relevant to incident

  • Provide additional photos relevant to incident

  • Provide additional photos relevant to incident

  • Provide additional photos relevant to incident

  • Provide additional photos relevant to incident

  • Provide additional photos relevant to incident

  • Additional Comments

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.