ADDENDUM “13” SIGN DESIGN & FABRICATION, INC. LIABILITY REPORT FORM

Date: __________

Claimant’s Name: ____________________________ Age: ______ Phone: _____________

Address: ___________________________________________________________________

Description of Occurrence: ___________________________________________________

___________________________________________________________________________. Injuries: __________________________________ Medical Care? YES NO Ambulance? YES NO Hospital or Doctor: _________________________________ Property Damage? YES NO describe same: _________________________________

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Is a Product Involved? YES NO Name and Size: _______________________________ Name and Address of Manufacturer: ___________________________________________

.

Did Claimant Slip, Fall, or Trip? ___________ Was Area Inspected? YES NO Foreign Matter or Debris Found on Floor? YES NO Describe: __________________

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Witnesses: Name: _____________________________________ Phone: ____________ Address: ________________________________________________________ Name: _____________________________________ Phone: ____________ Address: ________________________________________________________ Photos Taken? YES NO Additional Remarks: ________________________________

Report Prepared By: _____________________________

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