Incident and Claims Report Form

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Please complete this report immediately upon notification of an event, occurrence or circumstance that may give rise to a claim for compensation for personal injury or property damage.

Do not admit or accept any liability. Please refrain from providing any personal comment and state facts only.

The Duke of Edinburgh’s International Award – Australia (or 'Duke of Ed') engages the services of insurance broker, Honan Insurance Group Pty Ltd (HIG). HIG may be able to assist with your insurance needs, including the policies which the Duke of Ed's Award Centres are required to hold. If you have any queries or would like to obtain further information, HIG may be contacted on DukeofEdinburgh@Honan.com.au.

Details of person reporting the incident

First Name

Surname

Gender

Role / Position

e.g. Award Leader

Relationship to Award

Date of Birth

Street Address

City

State

Postal Code

Phone

Mobile

Details of Award Centre

Name of Award Centre

Award Centre ID (from Online Record Book)

Numerals only. Please exclude the prefix (i.e. "AU0000").

Street Address

City

Division

Postal Code

Phone

Website

Details of injured party

Same as 'person reporting the incident'

Injured party

First Name

Surname

Relationship to Award

Gender

Date of Birth

Is the Injured party under 18 years old?

This needs to be confirmed separately to determine if Parent/Guardian details are required to complete the form.

Contact details

Street Address

City

State

Postal Code

Phone

Mobile

Parent/Guardian of Injured party

Please note: Injured parties under the age of 18 years old will not be contacted directly.

First Name

Surname

Gender

Date of Birth

Street Address

City

State

Postal Code

Phone

Mobile

Details of incident

Date of incident

Time of incident

Enter as XX:XX

AM/PM

Location of incident (i.e. Street Address or Google Maps hyperlink)

For Google Maps: enter the location, select 'Share' and then 'Copy Link'.

Description of Incident

Please include any observations or concerns that need to be reported.

Details of injury / property damage

Additional details of the injured party

Provide a physical description of the person.

Describe the clothing and footwear worn at the time of the incident.

Was the person engaged in any activity that may have contributed to the incident?

YesNoi.e. running, carrying a heavy load, drinking, etc.

You answered "Yes". Please give details below.

Was the person's eyesight or hearing impaired?

YesNo

Did the person have a pre-existing medical condition or disability?

YesNo

You answered "Yes". Please give details below.

What were the weather conditions at the time of the incident? (if applicable)

Additional details

Details of Witness

First Name

Surname

Phone

Details of Award Centre insurance

Insurance Broker Name

Phone

Postal Address

City

State

Postal Code

Details of any Activity or Service Providers

Select checkbox below if not applicable

Not applicable

Activity or Service Providers

Activity/Service Provider Name

Phone

Postal Address

City

State

Postal Code

Details of any Activity or Service Providers Insurance

Select checkbox below if not applicable

Not applicable

Activity or Service Providers Insurance

Insurance Broker Name

Phone

Postal Address

City

State

Postal Code

Important notes

If possible, please obtain the following information and indicate how you will share this information with the National Award Office (NAO).

	Upload to this form	Fax to NAO	Email to NAO	Unavailable	Not applicable
Photographs of the incident site.
Photographs of the injuries sustained.
Statements from all witnesses.
All other investigation reports and diary records.

Photographs of the incident site.

Please upload as one Word (.doc) or Acrobat (.pdf) document.

Photographs of the injuries sustained.

Please upload as one Word (.doc) or Acrobat (.pdf) document.

Statements from all witnesses.

Please upload as one Word (.doc) or Acrobat (.pdf) document.

All other investigation reports and diary records.

Please upload as one Word (.doc) or Acrobat (.pdf) document.

This information must be provided to the National Award Office by fax (02) 9251 8993 immediately upon completion.

This information must be provided to the National Award Office by email (admin@dukeofed.com.au) immediately upon completion.

Upon selecting "Submit" below, you will be taken to a page where you can review all your responses prior to submission.

To finalise your submission, you will need to select "Submit" from the review page.

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