Retail Public Incident

IMPORTANT: THIS FORM MUST BE COMPLETED IN FULL (WITHIN 12 HOURS AFTER THE INCIDENT)

Basic claim information
Your email address *
Location Address
Store No.
Store
Location code
Address
City
State
Zip
Phone
Claim #
Incident report
If checked - do not contact claimant at this time -- no apparent injury.
Personal injury
Property damage
Property damage amount
Time and place of accident
Accident Date
Time
 hh:mm
Day of the week
Date reported
Time
 hh:mm
Store name
Location of accident
Aisle #
03 Bakery
11 Dairy
20 Flower Shop
23 Gen Mgr/MBA
37 Meal
46 Produce
53 Stockroom
Entrance
09 Checkout
12 Deli
21 Frozen Foods
24 Delivery
38 Office
50 Service Desk
60 Wall to Value
Other
08 Cart Storage
18 Employee Lounge
22 Gas Station
36 Liquor
42 Parking Lot
70 Sidewalk
70 Video
Customer information
Name
Birthdate
If married, spouse's name
Address
City
State
Zip
Home Phone
Employer
Work Phone
Comments
Description of accident as customer reported
Injuries Claimed
Medical treatment sought?
Yes
No
If yes, where?
Injured person's comments and attitude
Scene of the accident
Weather
Lighting
Photos taken?
Yes
No
By whom?
Date
Time photos were taken
 hh:mm
Warning signs?
Yes
No
Mats?
Other? Describe
Contract cleaning?
Yes
No
Was lot/walkway shoveled/ plowed and/or salted?
Yes
No
Contract plowing?
Yes
No
Aisle inspection sweep log attached?
Yes
No
Additional comments
Witnesses
Name
Address
Phone
Customer
Employee
Name
Address
Phone
Customer
Employee
Product involved (save product if possible)
Product name
Who has product now?
Date purchased
Expiration date
Receipt attached?
Yes
No
Describe any defect
Supplier/Vendor/Contractor involved?
Yes
No
Name
Address
Phone
Property damage
What damage does customer describe?
Describe any apparent injury or damage
Clothing soiled?
Yes
No
Clothing torn?
Yes
No
Which article?
Cause of soil or tear
Other damage
If damage to car by shopping cart, answer the following:
Was an employee assigned to gather carts?
Yes
No
Was the weather windy?
Yes
No
Stormy?
Yes
No
Was lot reasonably clear of carts?
Yes
No
Is parking lot angled/sloped?
Yes
No
Flat?
Yes
No
Are cart corrals provided?
Yes
No
Inspect damage: reasonable for cart to cause?
Yes
No
Of recent origin? (not rusty)
Yes
No
Year
Make
Model
License Plate #
Location of damage on car
Photos attached?
Yes
No
Cause codes: choose the cause code that best describes this incident
Cause Code
ALLEGES HARRASSMENT OR UNLAWFUL DETENTION
CAR DAMAGED IN LOT - ALL OTHER CAUSES
CHILD FELL FROM SHOPPING CART
CLOTHING CAUGHT ON SHARP OBJECT
FAINTING, PASSING OUT, DIZZINESS
FALSE ARREST
FOREIGN SUBSTANCE IN PRODUCT
ILL FROM EATING PRODUCT
INJURED BY ANIMAL OR INSECT
INJURED BY CONTACT WITH AUTOMATIC DOOR
INJURED BY PERSONS OTHER THAN EMPLOYEE
INJURED BY SPILLED PRODUCT
INJURED OPERATING MACHINE
OTHER MISCELANEOUS CAUSES
PROPERTY DAMAGED BY SHOPPING CART
PROPERTY DAMAGED BY SPILLED PRODUCT
SLIP, TRIP, FALL INSIDE
SLIP, TRIP, FALL OUTSIDE
STRUCK AGAINST OBJECT
STRUCK BY DOOR
STRUCK BY EMPLOYEE
STRUCK BY FLYING OR FALLING OBJECT
STRUCK BY SHARP OBJECT
STRUCK BY SHOPPING CART IN PARKING LOT
STRUCK BY SHOPPING CART IN STORE
Date of this report
Completed by
Title
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