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3939 Bee Caves Road
Building A, Suite 1B
Austin, Texas 78746
Telephone: 512-328-6812
Toll-free: 888-842-7491
Fax: 512-327-9775
Email: admin@texasmuseums.org
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Home > TAM
Publications > PREP Form 27
PREP -- Accident Report Form for Visitors
Timely and thorough investigatin of an accident is essential
to you and your insurance company. A proper investigation will preserve
information that may be difficult to uncover at a later date. Note the
following information when investigatin accidents that result in bodily
injury or property damage to third parties on your premises.
1. When investigating an incident always ask the basic questions
- who, what , where, when, why and how. With this as a framework,
you will be most likely to gather the necessary information. |
2. ALWAYS COMPLETE AN ACCIDENT INVESTIGATION FORM REGARDLESS
OF HOW MINOR THE INCIDENT APPEARS. Something that appears minor
at the itme could develop into a serious claim at a later date. |
3. ALWAYS CALL THE POLICE AND AN AMBULANCE IF SOMEONE IS INJURED
ON YOUR PREMISES. |
4. IF THERE ARE WITNESSES PRESENT, ASK THEM FOR
A STATEMENT. If they do not want to give a statement, get names
and addresses of the witnesses. |
5. REPORT ALL ACCIDENTS TO YOUR AGENT OR BROKER AS SOON AS POSSIBLE.
This facilitates the handling and investigation of a claim. Failure
to report a claim in a timely manner may jeopardize the effective
handling of the claim or suit. |
6. IF THE ACCIDENT WAS CAUSED BY SOME PARTY NOT ASSOCIATED WITH
YOUR INSTITUTION, ADVISE YOUR AGENT OR BROKER OF THAT FACT. If an
independent contractor caused the loss, it could relieve you of
legal responsibility. Copies of contracts and/or invoices could
play a crucial role in the outcome of the claim. |
7. TAKE PHOTOS OF THE SCENE AND SECURE PHYSICAL EVIDENCE IF APPROPRIATE.
If, for example, a patron sat on a chair and it collapsed, keep
the chair and have it available for your insurance company to inspect. |
Institution Name___________________________________________________
Location of Accident________________________________________________
Date/time reported ___________________Date/time occurred_______________
Name of injured party _______________________________________________
Address__________________________________________________________
_________________________________________________________________
Age ______________________________ Phone #_________________________
Describe injury _____________________________________________________
_________________________________________________________________
Police/Ambulance called _____________________________________________
Time arrived _________________________Report Number _________________
Transported to___________________________ by ________________________
Narrative ( who, what , where, when, why and how.) _________________________
_________________________________________________________________
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Witness________________________ Relationship ________________________
Address_______________________________Phone_______________________
Witness________________________ Relationship ________________________
Address_______________________________Phone_______________________
Were photos taken? _____________ Location of Photos______________________
Name of Person completing the report____________________________________
Date____________________
Witness Statement
Below is a written statment voluntarily given by a witness to an accident
that occurred at the premises described below on the date indicated.
Premises__________________________________________________________
__________________________________________________________________
Date of accident_____________________________________________________
Injured party ________________________________________________________
Relationship to injured party ___________________________________________
Witnesss Name____________________________________________________
Statement _________________________________________________________
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Signature of Witness ______________________________Date________________
Address ___________________________________________________________
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