Incident Report Form If you are currently signed to IMAE, please fill this form to report an incident. Please be aware that the Standard Excess on the Liability policy is $2,500.00 for Each & Every Claim. Your detailsPlease provide your details.Date Today* DD MM YYYY Name* First Last IMAE Membership Number*Business NameEmail* Enter Email Confirm Email Phone*IncidentPlease provide details of the incident. If any of the space is insufficient, please use the File Upload section below.Date of the incident* DD MM YYYY Time of the incident* : HH MM AM PM Name/s of person/s involved in the incident*Please include contact details if available. This may include a patron, employee, or crowd controller if applicable.Description of the incident*WitnessesPlease include contact details if availableDamage to inventoryPlease provide details of any damages to stock/inventory and their respective monetary value if applicable.Have the police attended to deal with the incident?* Yes No Police Incident NumberPlease provide a police incident number or the name/rank of the attending officer/s if applicable. Please include the time the officer began dealing with the incident and their contact details.Has an ambulance been involved or has a first aid kit been used?* Yes No Ambulance / first aid kit detailsPlease provide any relevant details of the ambulance involvement or the use of a first aid kit.Was the incident recorded by an electronic surveillance device?* Yes No Surveillance detailsPlease provide details of the surveillance device including ownership and how to obtain a copy of the surveillance.File UploadPlease provide files relevant to the incident if available. Drop files here or Accepted file types: jpg, jpeg, png, pdf, doc, docx. ConfirmationThank you for providing the necessary details. Please proceed by confirming the details below.Please confirm* I have a have an active membership with IMAE I have fully read and understand the IMAE Terms and Conditions I confirm that the above information is true and correct
