Incident Report/Investigation Form

Club Details

Club's Name

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State

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Name of Member Involved(*)

Membership No. AUS

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Mobile(*)

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Particulars of Incident

Describe the incident.

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Date

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Time

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AM/PM

Where did the incident happen?

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How did the incident happen?

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Number of flights that day prior to incident

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Witnesses

Name

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Contact Number

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Damage Caused to Property

Not Applicable

- Tick if Not Applicable Invalid Input

Description of Property Damage

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Details of Model

Type

Free Flight Control LineRadio ControlOther Invalid Input

Other

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Wingspan - cm

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Weight - kg

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Engine Capacity/Thrust

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Confirmation of Incident Report

All communications received from parties in this occurrence of their representatives should be immediately forwarded to the company unanswered. Do not admit liability nor reveal to the third party that you are insured.

- I hereby declare and warrant that the foregoing particulars are true. Invalid Input

Name of Submitter

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Position

Club Safety OfficerContest DirectorOther Invalid Input

This Form is for information purposes only. The conclusions set out in the Form are as a result of a preliminary investigation by the signatory and do not constitute in any way an admission or acceptance of any liability by or on behalf of the MAAA, its Members, or Affiliate Members.

(*)

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