Motorsports Incident Report

Date & Time of Incident:
Happened During:	Practice Race
Sanction for Event
How Did Incident Happen:
Witness Name:
Address/Phone
Location:	Track Pits Grandstands Bleachers Infield Parking Area Other
Other explain:

Name:
Address
Phone:
Date of Birth (Age):
Name of Parent, if Minor:
Nature of Injury:
Type of treatment given on site:
Was ambulance transport required:	Yes No
If yes, hospital transported to:
Was further treatment recommended?	Yes No
Did party sign waiver?	Yes No
Any photos of area/accident?	Yes No
Any video of area/accident?	Yes No

Name of person filling out this form:
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Send all information immediately after incident to:

Naughton Insurance Inc.
P.O. Box 6192, Providence, RI 02940.
(401)433-4000 Fax (401)433-5460
info@naughtoninsurance.com

Email: info@naughtoninsurance.com
Tel: 401-433-4000
Fax: 401-433-5460