Amusement Park Incident Report

Name of Park:

Device or Location of Incident:

Operators (Attendants):

Address:

Phone:

Date & Time of Incident:

Weather:

How Did Incident Happen: (If Slip & Fall Include Dated Photos)

Was site or area inspected after incident:

Yes No

Result of Inspection:

Name:

Address:

Phone:

Date of Birth (Age):

Name of Parent, if Minor:

Email:

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 return to amusement park?

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