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Incident Report Form - Personal Injury Or Property Damage - Australian Endurance Riders Association

AERA

INCIDENT REPORT – PERSONAL INJURY OR PROPERTY DAMAGE

This report is to record any injury sustained by any person or damage to any property (includes a horse),

whether incurred at the ride base or on course. This report provides the primary information should a

subsequent insurance claim be made against the ROC, Ride Officials or the AERA following such injury or

damage. Any person may complete this Incident Report which must be lodged with the chief steward before

departing the ride base at the completion of the event. A separate Incident Report form must be used for

each Incident and for each witness to the incident.

NAME OF EVENT:

STATE

DATE OF EVENT

CHIEF STEWARDS NAME:

PHONE:

EMAIL:

NAME OF PERSON COMPLETING THIS REPORT:

SIGNATURE:

YOUR RELATIONSHIP TO THE INCDENT:

(

) Injured party

(

) Owner of the damaged property

(

) Witness

DETAILS OF INCIDENT:

SPECIFIC LOCATION OF INCIDENT: e.g. VET RING, CAMP, ON COURSE

DATE:

TIME:

DESCRIPTION OF INCIDENT: (IF SUFFICIENT SPACE ATTACH A SEPERATE PAGE).

CONTACT DETAILS OF EACH PERSON INVOLVED IN THE INCIDENT:

NAME:

PHONE:

EMAIL:

NAME:

PHONE:

EMAIL:

NAME:

PHONE:

EMAIL:

CONTACT DETAILS OF ANY WITNESS TO THE INCIDENT:

NAME:

PHONE:

EMAIL:

NAME:

PHONE:

EMAIL:

NAME:

PHONE:

EMAIL:

Last Update 2015.12.31

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Incident Report Form - Personal Injury Or Property Damage - Australian Endurance Riders Association

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