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 #
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?
If yes, where?
Injured person's comments and attitude
Scene of the accident
Weather
Lighting
Photos taken?
By whom?
Date
Time photos were taken
 hh:mm
Warning signs?
Mats?
Other? Describe
Contract cleaning?
Was lot/walkway shoveled/ plowed and/or salted?
Contract plowing?
Aisle inspection sweep log attached?
Additional comments
Witnesses
Name
Address
Phone
Name
Address
Phone
Product involved (save product if possible)
Product name
Who has product now?
Date purchased
Expiration date
Receipt attached?
Describe any defect
Supplier/Vendor/Contractor involved?
Name
Address
Phone
Property damage
What damage does customer describe?
Describe any apparent injury or damage
Clothing soiled?
Clothing torn?
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?
Was the weather windy?
Stormy?
Was lot reasonably clear of carts?
Is parking lot angled/sloped?
Flat?
Are cart corrals provided?
Inspect damage: reasonable for cart to cause?
Of recent origin? (not rusty)
Year
Make
Model
License Plate #
Location of damage on car
Photos attached?
Cause codes: choose the cause code that best describes this incident
Cause Code
Date of this report
Completed by
Title
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