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 details
Please provide your details.
Date Today*

DD
MM
YYYY
Name*
First Last
IMAE Membership Number*
Business Name
Email*
Enter Email Confirm Email
Phone*
Incident
Please 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
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*
Witnesses
Please include contact details if available
Damage to inventory
Please 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 Number
Please 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 details
Please 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 details
Please provide details of the surveillance device including ownership and how to obtain a copy of the surveillance.
File Upload
Please provide files relevant to the incident if available.
Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx.
Confirmation
Thank 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

Your details

Incident

Confirmation