- Provide Company Information if applicable
- Provide location of your Company Headquarters
Slip and Fall or Other Liability
- Provide location where accident occurred
All Liability Claims
- Your Business name & address (include specific division if applicable and mailing address if different than above.
- Specifics e.g. aisle of fall, Dept.
- Date & time of accident
- Detailed description of accident
- how was product being used
- specify manufacturer's name
- make/model/size/style/serial # and/or product I.D.
- was there damage to product
- where & when purchased
- where & when can product be seen
SAVE THE PRODUCT INVOLVED FOR INSPECTION
DO NOT DESTROY
Slip and Fall
- What substance or object did claimant slip/trip or fall on (if any)
- How did substance or object get there
- Witnesses including specifics on where they were at time of accident, any relationship to involved parties and means of contact (address, phone #, best time & place)
- Authorities (ambulance, police, fire) include address, report # and any violations/citations that may have been issued
- Nature of Occurrence Were there complaints of injuries (any special treatment)?
- Was there any damage to property you don't own?
- If yes, refer to info needed in "property damage" section
- Name, address, home & business phone for injured
- Occupation (if provided)
- Date of birth (age) Social Security # & sex
- Description of injury
- Was medical treatment received? If so, from who
- Name, address, phone # of hospital/clinic/doctor
- Type of treatment, length of stay, specialty of doctor
- First day of treatment
- Is injured represented by an attorney?
- Name, address & phone number
- Was lawsuit served? If yes, date of service
- Employer Information (Name, address & phone) (If multiple injuries, repeat above section)
Property Damage Information
- Property owner's name, address, home and business phone
- Description of damage (include both description of item and damage to that item)
- Estimate of damage, if available (If other property damage, repeat above section)
Account Contact Information
- Best person (including time & place) to contact for more information
- Additional comments and information