Incident Report Form

First Name *

Last Name *

Postal Address *

Suburb *

State *

Post Code *

Phone Number *

Email Address *

Description of incident/occurrence *

Date of Incident * +

Time of incident

Was this reported to a staff member on site? *

Yes

No

Name of staff member this incident was reported to

Were there any witnesses? *

Yes

No

Name of witnesses and contact details (postal and phone please) *

0/255 characters

Specific location of incident/occurrence *

0/255 characters

Location *

You must include a marked map to pinpoint the location of the incident *

Maximum file size 20MB and one (1) file

CONDITIONS

Weather *

Lighting *

None

Artificial

Not Working

Contributing Factors *

Comments *

Property Damage *

Yes

No

Estimated cost *

Have you provided two (2) "like for like" quotes? *

Yes

No

This information is mandatory upon submission.

Please upload a copy of your quote

If you have additional documents, please upload them below.

Damage Details *

Personal injuries sustained *

Yes

No

Estimated cost *

Have you attached invoices for out-of-pocket expenses & evidence of attendance to a medical professional? *

Yes

No

Please upload your invoice *

This information is mandatory upon submission.

Personal Injury Details *

Photographs of damage/injuries? *

Yes

No

Upload your photos (Maximum of 6 files with a file size of 20MB) *

This information is mandatory upon submission.

I agree that the information I have supplied is true and correct. *

Yes

Signature - You can use your mouse or stylus to complete your signature.

clear

Date * +

Please note: Your claim will not be processed until all the above requested information is received.

Townsville City Council collects and manages personal information in the course of performing its activities, functions and duties. We respect the privacy of the personal information held by us. The way in which Council manages personal information is governed by the Information Privacy Act 2009 (Qld). We are collecting your personal information in accordance with Insurance Act 1973 so that we can investigate and assess your insurance claim. Generally, we will not disclose your personal information outside of Council unless we are required to do so by law, or unless you have given us your consent to such disclosure. However, in performing the above functions, we may need to disclose your personal information to the Council Insurer and their contacts. For further information about how we manage your personal information please see our Information Privacy Policy.

Dam	Reserve	Road
Footpath	Building	Other Other

Wet	Dry
Sunny	Overcast
Other Other

Uneven ground	Pavement
Hole	Tree
Other Other