Incident Report Form Please Print - Kin Canada
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2Kin Canada
INCIDENT REPORT FORM
Report any incident that might lead to a claim against Kin Canada policies by:
1. Immediately following the incident, call National Headquarters at 1-800-742-5546, ext. 208, to report
the incident.
2. Follow up immediately completing and submitting an Incident Report Form to National Headquarters,
preferably by fax to 1-519-650-1091.
PLEASE NOTE: This Incident Report Form must be received at National Headquarters no later than 24
hours after the incident. Failure to notify may result in loss of Insurance coverage. Information collected
within this report will be retained according to the Association’s Privacy Policy.
PLEASE PRINT
TYPE OF INCIDENT:
Accident or Injury
Property Damage
Public Disturbance
Service Refused
Ejection of Patron
Minor on Premise
Theft
Other
CLUB/ZONE:
DISTRICT:
DATE:
TIME:
WEATHER:
LOCATION OF INCIDENT:
LOCATION OF INCIDENT:
(Address)
(Hall, Parking Lot, Washroom etc.)
PERSON COMPLETING THIS REPORT:
WHAT KIN WERE INVOLVED IN THE
Name:
INCIDENT?
Address:
City:
Postal Code:
Phone No.:
Cell No.:
PATRON INFORMATION:
PATRON DESCRIPTION:
Name:
Male
Female
Weight:
Height:
Eye Colour:
Address:
Hair Colour:
Beard or Moustache?
Glasses:
City:
Age: Under 19 19-30 31-40 41-50 51-65 66+
Postal Code:
Ethnic Background:
Phone No.:
Distinguishing Marks:
Cell No.:
Other:
DESCRIPTION OF INCIDENT:
Use additional paper if needed
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Parent category: Business