Naui Accident Report Form Page 2
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5VICTIM INFORMATION:
Name_______________________________________________________________________
Address_____________________________________________________________________
Phone Number______________________ Age ________ Date of Birth _______________
Gender (check): ___M ___F
Marital Status___
Height__________ Weight___________
Certified Diver: ___ Yes ___ No If YES, what agency?_____________________________
Level of Diver Certification___________________ Occupation_________________________
Date of Incident _____________________ Time of Incident____________________________
PERSON MAKING REPORT:
Name________________________________________________________________________
Address_______________________________________________________________________
______________________________________________________________________________
Phone Number: Work ______________
Home _________________
Did you witness the incident? ___ Yes ___ No
Are you a Certified Diver? ___ Yes ___ No
Level of Diver Certification________________________________________
Relationship to accident victim_____________________________________
DIVING LEADER INFORMATION:
Name_______________________________________________________________
Address______________________________________________________
Phone Number: Work _________________
Home __________________
Agencies certified by_______________ Level of Diver Certification_________
Professional liability Insurance company_____________________________
WITNESS INFORMATION:
Names, addresses and phone numbers of key witnesses (if witness statements are taken, be sure
the statements provide only facts and no opinions. Have witness date and sign each page. Attach
copies to this report)
NAME
STREET
CITY, STATE, ZIP
TELEPHONE
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do not provide this report to any other party.
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