Please note that this form is to be filled in by a member of the committee, a group convenor, or the property owner and should be retained on file by the U3A committee in case of a claim and for a period of three years even if a claim appears unlikely.

1. Your details

u3a
Name
Position
Email
Telephone
Address
Postcode

2. Incident Details

Date of Incident
Time of Incident
Where did the incident occur?
Please state the reason for the injured person or damaged property being there.
Please describe the circumstances of the incident. (Attach a sketch or photograph if possible).

3. Particulars of the injured person(s). (Continue on a blank sheet if necessary).

Name
Address
Postcode
Email
Telephone
Was she/he a member of u3a on the day of the incident?

4. Details of the injury

Describe the injury/injuries
Immediate action taken
Treatment at the scene
Admission to hospital
Ongoing treatment

5. Details of damaged property

Describe damage caused
Estimated cost of repair
Name of owner of damaged property
Address
Postcode
Email
Telephone

The remaining sections are to be completed for all incidents

6. Name and contact details of any witnesses to the incident

7. Declaration

I/we declare that to the best of my/our knowledge and belief, all the foregoing particulars are true and correct in all respects

Signed

Date