Evergreen MGA

Incident & Bodily Injury Report Instructions

This form is provided to advise you of the information we will need to begin an investigation. If you are already using a form please check to see that your form includes the information requested here.

It is to your advantage to gather the information requested even if the person/or persons involved in the incident states that they have absolutely no intention of making a claim. Many times these are weak cases and the inability to make a timely investigation works against you, when they in fact do make a claim.

What to do if you have a loss

1.  Do NOT pay or make any financial obligations.
2.  Do NOT make statements which assume responsibility.
3.  Provide needed medical assistance.
4.  Gather information.
5.  Preserve all evidence, if needed photograph the scene.
6.  Eliminate any immediate hazard, without destroying evidence.
7.  Notify police if a law may have been broken.
8.  Complete incident report form.
9.  Report to insurance company.
10. Keep information confidential.

Block #1 includes information to identify your campground, RV park, or paddlesport operation and to whom we (the claims management company) should address any inquiry.

Block #2 asks you to identify when and where the event took place. Date of Incident is the actual date the event took place. Date Incident Reported is the date you (or your staff) became aware of the event. Time Incident Occurred is the time, as best you can, determine the event occurred. Specific Location is where the event took place. Example: Bathhouse by site 23, 3rd shower from left or At river behind site 32.

Block #3 asks for information about the person injured or involved in the incident.

Person's name: State, as completely as is known, the name of the injured person or the person involved. Complete an additional form for each person involved.

Age, if exact age is not known simply estimate. Example: 18/19, mid 20's, over 65.     

Sex: Enter M or F

Registered Guest is important since the level of care to which a person is entitled may depend on whether they were registered. A copy of the registration card can be attached to this report and kept in your file.

Person's Address: addresses of person involved. This may not be the same as person who registered at check in. Please check and list correct information.

Name of Parent/Guardian: List the name(s) of the person(s) who accompanied the minor, or were responsible for the minors.

Indicate parent or guardian as applicable and if guardian; indicate relationship, such as "grandfather". If parent or guardian's address is different than the minor's, list their address in the notation section.

Phone #/Notations: This line, in addition to a phone number, might include something such as, "was part of Springfield Elementary School field day group".

Block #4 provides space for a brief description of what happened. Example, "Jimmy fell in the shower area. He hit his head on the floor, just outside of the shower stall. The floor in front was wet from the shower." Keep the description short, to the point and stay to the facts, as you know them. Do not draw conclusions. If you are restating what someone told you, say, "Jimmy said, he fell and hit his head. The floor in front of the shower stall was wet from the shower." Photographs and drawings may be included. Written by should specify the name of the staff member who wrote or provided the section 4 information.

Block #5 requests information as to what was the medical response, if the incident involved an injury.

Was first aid provided at scene? First Aid includes applying bandages, disinfectants, blankets for warmth, CPR, etc. Indicate yes, or no. If medical assistance was provided to the injured person, whom asks, who provided that service, (proper name or agency) and (yes or no) if they were park staff. Additional information on this person or persons should appear in the witness section unless EMT personnel.

Taken for Treatment means medical treatment away from the campground, such as a hospital, clinic, etc.

If NO, was treatment recommended. YES means, you felt that the injury should have been looked at by medical professionals and you suggested that the injured person be taken to or go to a medical facility, but they did not go. No means you felt treatment was not needed and you did not suggest.

If treated, where? asks for the proper name of the medical facility, hospital.

Transported By: asks for the specific name of the ambulance service or a statement such as, "own vehicle" or "Sam Smith friend".

Describe Injury and Treatment asks for a brief, non technical description of what kind of injury the person appeared to have. Include what body part or area of the body appeared to be injured and what if anything was done at the campground to treat the injury or comfort the person. Example "Jimmy appeared to have a small cut on his forehead, a bandage was applied to control the bleeding. He was covered and kept still until the ambulance arrived."

Block #6 makes an inquiry into who might have seen the incident or have been involved immediately after the incident occurred. This should include both campers and campground employees.

Name:   Proper name as best known. If no witnesses write "None". If not aware of any, write "Unknown".

Eye Witness or Second Hand: simply indicate which description applies. Eye witness is someone who actually saw the event as it happened; Second Hand witness is someone who did not observe the event as it happened but was on the scene immediately or shortly thereafter. These types of witnesses may be able to provide a great deal of information regarding the environment, how the situation was handled and the condition of the injured person.

Do not be selective, in the sense of picking witnesses that may be favorable to one side or the other. List all witnesses that you feel may have seen the event or have information relative to the incident. It is not necessary for you to interview or "take statements". That can be done later. It is important to identify witnesses, so that our office will be able to contact them at a later date.

Relationship: this asks how the witness is associated with the person involved in the incident. The relationship might be wife, husband, camping companion, park employee, nearby camper, friend, guest, etc.

Address: should be this person's permanent address.

Phone #/Notation: in addition to the phone number this space is also to make any comments. Comment examples might be "helped with first aid" or "was walking with Sally" (the injured person).

Reporting Section

Date Carrier Notified: Enter the date that this form was forwarded to the insurance carrier, and how, by mail, fax, phoned in, etc.

Block #7 Notes might list any follow-up action taken, or a statement as to what was done with any evidence, such as where & how it was stored or that the equipment was inspected prior to being put back into service. The last line is completed and dated by the person who completed and checked the report.  

Filing: You should keep this report in your file. Check with your attorney regarding the statute of limitations in your state. (If the incident involves a minor it would be advisable to retain the report until the minor would reach the age of eighteen or twenty-one.) We would suggest filing these forms by INCIDENT DATE. If a claim is made the claimant will have to provide the incident date. Since the person involved does not complete the form and does not check the information, their name may be misspelled and in turn mis-filed.

Management Tool: By completing this form for all incidents you are developing very useful information about your campground, RV park, or paddlesports operation. A periodic review of these reports may help you identify problem areas or activities and in turn allow you to initiate corrective action.