Report an Incident : Western Bowling Proprietors Insurance

Name of Bowl *

Date of Incident *

Approx Time *

Bowl Phone Number *

Bowl Contact Person

Reported by Signature

Injured Party’s Name *

Age

Male or Female *

Male
Female

Injured Party’s Phone Number *

Work

Cell

Mailing Address

City *

Zip

League Bowler?

Yes
No

Alcohol Involved? *

Yes
No

Non-Bowling Injury?

Yes
No

What kind of shoes was the injured party wearing? *

Rented Bowling Shoes
Their Own Bowling Shoes
Street Shoes
Socks only
Sandals
No Shoes
Other

If a bowling injury, in what frame and ball were they injured? (ex: first frame, second ball)

Part of the body injured *

What caused incident *

Witness Name

Witness Phone

Related to Injured Person?

Yes
No

Witness Name

Witness Phone

Related to Injured Person?

Yes
No

Was Medical Attention Needed? *

Yes
No

Paramedics?

Yes
No

Went to Hospital?

Yes
No

Medical attention provided by bowl

Injured party continue to bowl? *

Yes
No

Do you think a claim will be made? *

Yes
No
Unknown

Did injured party say they had medical insurance? *

Yes
No

Name of carrier

Injured party’s attitude *

Friendly
Mad
Threatening
Calm
Scared
Demanding

Explain in detail *

Report an Incident

Download the WBPI Incident Report or fill in the form below.