Preview Insurance Incident Report

Silent Sports Association Incident Report

It is important to have written incident reports on file regarding injuries, property damage or other

incidents that may result in a claim against your sports organization. Many such claims allege negligence,

and written reports prepared immediately after an incident occurs are invaluable in defending these types

of claims. In the event of a serious injury, it is important to ask for written statements from witnesses and

individuals actually involved in the incident. One copy of the report should be kept on file with your

organization for at least three years since many lawsuits are filed long after the injury occurs. One copy

should be forwarded to McKay Insurance Agency – contact information is at the bottom of page two.

Attach any additional information that might be helpful in defense of a future claim, such as a police

report, doctor’s statement, pre-event inspection report, routine facility maintenance report, photos taken at

the time of the incident and written statements of witnesses.

This report is to be completed by:

An official member of the organization for incidents occurring during covered activities or events. This

may be a race director, a bike tour guide, the president of a bike club, etc.

1. General Information

DATE AND TIME OF REPORT:

REPORTER’S NAME:

POSITION: __________________

HOME ADDRESS:

PHONE (H):

PHONE (W):

PHONE (CELL):

EMAIL:

EVENT/ACTIVITY:

DATE AND TIME OF INCIDENT:

LOCATION OF INCIDENT:

2. Provide full description of all events leading up to and including the incident:

(Attach a longer description if necessary.)

3. Witnesses

Full Name Address Statement Attached (Y/N)

_____________________________________________________________________________________________

Incident2003

NAME OF CLUB / ORGANIZATION:

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