Amusement Park Incident Report

Insured Information

Name of Park:
Device or Location of Incident:
Operators (Attendants):

Incident Information

Date & Time of Incident:
How Did Incident Happen:
(If Slip & Fall Include Dated Photos)
Was site or area inspected after incident:

Result of Inspection:

Injured Party

Date of Birth (Age):
Name of Parent, if Minor:
Nature of Injury:
Type of treatment given on site:
Was ambulance transport required:
If yes, hospital transported to:
Was further treatment recommended?
Did party return to amusement park?
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

[ Click here for a printable version ]

Physical Address - 1365 Wampanoag Trail, East Providence, RI 02915
Mailing Address - P.O. Box 6192, Providence, RI 02940
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