Incident Report Form

Leavitt Recreation & Hospitality

Insured Information

Information About the Person Involved in the Incident

Information About the Incident

Reporter Information


Basic Rules for Incident Investigation

  • Call an ambulance if requested or obviously necessary
  • Make injured party as comfortable as possible until help arrives
  • Take photos of the damage or where the incident occurred
  • Ensure hazardous conditions are corrected immediately
  • Preserve any evidence which may assist with any investigation
  • Don’t admit negligence
  • Interview witnesses at the scene in private
  • Obtain contact information for witnesses
  • Get signed statements from all involved
  • Determine what may have caused or contributed to the incident
  • Make any corrections to prevent future similar incidents


The information and suggestions presented by Leavitt Recreation & Hospitality Insurance in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises, preventing possible workplace accidents, or complying with all of the local, state or federal health & safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards.