Please answer all questions. If you don’t have all information, please interview a person who does. When completing this form, please provide FACTUAL INFORMATION ONLY.

Do not admit liability, accept responsibility or promise/offer compensation under any circumstances. Do not delay in completing this form to Marsh Pty Ltd. Failure to do so could jeopardise the entitlement to indemnity under the Public Liability Policy.

First Name(s): *  
Surname: *  
Official Position: *  
Contact Phone:
Email Address:  

Event Details

State: *  
Track Name / Venue: *  
Incident Date:  
What time did the incident happen?: *  

Incident Details

Where did the incident happen?:
e.g on track, pits, general admission area
Describe how the incident occurred: *  
What form of lighting illuminated the area?:  
Please describe the lighting: *  
Track moisture?:  
Surface condition?:  
Who reported the incident to you?: *  
Address: *  
Telephone: *  
Were there any witnesses?:  
Please provide details: *  
Are photographs of the incident site available?:  

Injury Details

Name of the person injured:  
Approximate age:  
What injuries were sustained?:  
In your opinion, was the injury:  
Was the person a:  
Race Division: *  
Was it necessary to call for immediate medical assistance?:  
What level of medical assistance attended?:
e.g Doctor, Ambulance
Was the injured person transported to hospital?:  

Property Damage Details

Name of the damaged property owner (if known):  
Describe the damaged property:  
Describe the nature of the damage:  
What is the estimated cost of repair or replacement?: