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INCIDENT REPORT HOTEL CODE: TJBHS
GUEST/PATRON/THIRD-PARTY LOSS/DAMAGE Incident No.: D- Mo/Day/Year
TO PROPERTY or INJURY/ILLNESS
Claim Handing Instructions: Information Only Establish Claim
Hotel:
Name Home Phone: Work Phone:
Mr. Ms. Mrs. （ ） （ ） ext.
Address: (Street, City, State/Prov, Zip/Postal Code)
Registered Guest Patron Other Birthday/Approx. Age:
Room Number
Location of Incident:
Occurred and Reported on:
on Mo/Day/Year Time am/pm Mo/Day/Year
or Mo/Day/Year Time am/pm Time am/pm
between:
Type of Incident: Reported to: (name/title)
LOSS OF PROPERTY DAMAGE TO
PROPERTY INJURY/ILLNESS
If loss/damage to property, describe item(s): Guest estimate of loss
damage ：￥
If injury, nature of injure: Part(s) of body affected: (Be specific)
Visible injuries:
Claimed injuries/illness:
First Aid Offered: Yes No Accepted: Yes No Administered: Yes No
If administered, type of first aid: Administered by: (name, title)
Transported to doctor/hospital: If so, transported by:
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