General Liability Incident Reporting Form For Guest & Tenants

General Liability Incident Reporting Form for Guests & Tenants

General liability (GL) is meant to cover resulting damage arising out of the alleged negligence of Quest Asset Management, Inc .. The accident can involve an injury or property damage to some else’s property, which is not managed by Quest Asset Management, Inc. Examples of GL claims - slip & fall, bodily injury, assault, gate hitting vehicle, etc.

This report is to be completed within 24 hours of when you receive notice of an incident/injury and faxed or emailed to the Dallas Office: Attention: Chris Evans ([email protected]). Call if you have questions: 214-675-8402.

(1) Date: (2) Date of Incident: (3) Time:

(4) Your Name: (5) Phone:

(6) Site Location Code of Property:

(7) Name of Property:

(8) Address of Property

(9) City, State, & Zip:

(10) Reason for being on the property: Resident ____ Guest ____ Other/describe:

(11) Describe incident/injury:

(12) Describe conditions at site of accident (ie, wet floor, ice, hole):

(13) Were Photos taken of scene? _____ Of claimant? _____

(14) Was 911 called? _____ Yes _____ No

(15) Claimant Name: (16) Phone:

(17) Address:

(18) Witness Name: (19) Phone:

(20) Address:

(21) Additional Pages Attached? _____Yes _____ No INSTRUCTIONS FOR COMPLETING GENERAL LIABILITY INCIDENT REPORTING FORM

1. Date: Enter date you are completing the form.

2. Date of Incident: Enter the date the incident actually occurred. If the person reporting the incident is not sure of the exact date, have them provide you with an estimated date. In the case of an estimated date, indicate the date entered is an estimated date.

3. Time: Enter the time of day the loss occurred. Be sure to indicate AM or PM. If time is estimated, so indicate.

4. Your Name: Enter your name.

5. Phone: Enter your property’s telephone number.

6. Site Location Code of Property: Leave blank.

7. Name of Property: Enter the full name of your property.

8. Address of Property: Enter the complete street address of your property.

9. City, State, & Zip: Enter city, state and zip code for your property.

10. Reason for being on the Property: Check appropriate reason.

11. Describe Incident/Injury: Enter a detailed description of the incident and/or injury. When describing the incident, provide as much detail as possible. Indicate how (example: fall), where (example: parking lot) and why (example: tripped over crack in pavement). When describing injury, be as precise as possible. For example, indicate right arm, left ankle, etc. Use additional sheets if required.

12. Describe conditions at the site of the accident: Enter detailed description, including weather conditions.

13. Were photos taken of scene? Of claimant?: Enter yes or no in appropriate space or spaces. Whenever an incident is reported, photographs should always be immediately taken of the location where the incident occurred. If it is necessary for a size of something to be seen, use a ruler next to it in your picture (beside a crack in pavement, for example). If the person involved is injured and you can get a photo of the injuries sustained by that person, you should do so.

14. Was 911 called? Enter yes or no.

15. Claimant Name: Enter claimant’s full name.

16. Phone: Enter claimant’s complete telephone number, including area code.

17. Address: Enter claimant’s complete address including street address, city, state and zip code. 18. Witness Name: Enter witness’ full name.

19. Phone: Enter witness’ complete telephone number including area code.

20. Address: Enter witness’ complete address including street address, city, state and zip code.

21. Additional Pages Attached: Enter yes or no.

NOTE: Additional pages should be attached to provide any details not included in the questions answered above or to continue those questions where the answer is longer than the space provided. When continuing information from a specific question on an additional sheet, be sure to identify the answer being continued. For example: “Item 11 continued”