SUPPLEMENTAL INCIDENT REPORT

If someone slips-and-falls in the community's common areas or parking lot, fill out our incident report form. Then use this form and fill out the answers to questions 1 through 8 and return both forms to the management office.

Named Insured:

Policy Number (if known):

Name of Community:

Name of Injured Person:

First NameLast Name

Address of Injured Person:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number of Insured Person:

Please enter a valid phone number.Format: (000) 000-0000.

Email of Injured Person:

example@example.com

YesNo

Take a photograph of the slip-and-fall site. Attach the photo to this jot form.

1. Size of hole, depression, bump or other defect (if there is one):

2. How well maintained was the slip-and-fall area at the time of accident:

(measure the depression, bump, hole, or defect with a ruler. Take a photograph of the ruler next to the defect to show its size. Also attach photo to this jot form.

YesNo

If yes, explain:

4. Did the accident occur indoors or outdoors?

If outdoors, describe the weather conditions and where the incident occurred:

5. How crowded was the slip-and-fall site at the time of accident?

YesNo

7. What is the state of repair of the slip-and-fall site (look at the area around the slip-and-fall site and state if the area is well maintained or if it is in disrepair):

YesNo