Incident Report/Investigation Form

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Club Details

Club's Name(*)
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Address(*)
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Postcode(*)
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State
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Phone
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We require one type of contact number.

Mobile
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Email(*)
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Name of Member Involved(*)
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Membership No. AUS(*)
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Member's Address(*)
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State
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Member's Postcode(*)
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Phone
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We require one type of contact number.

Mobile
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Member's Email(*)
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Particulars of Incident

Date(*)
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Time(*)
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AM/PM

Where did the incident happen?(*)
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State
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How did the incident happen?(*)
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Is an insurance claim being made against you?(*)
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Was it reported to police?
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Name of Officer
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(Optional)

Police Station Notified
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(Optional)

Witnesses

Name
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Address
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Post Code
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State
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Name
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Address
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Damage Caused to Property

Not Applicable
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Owner's Name
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Address
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Description of Property Damage
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Nature of Damage
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Estimated Cost $
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Injury to Persons

Not Applicable
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Name
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Age
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Nature of Injury
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Address
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State
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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.

Additional Comments
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Name of Secretary
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(*)
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Incident Form Details

Club Name(*)
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Name of Member involved
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Contact Name(*)
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Contact Email(*)
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Contact Number(*)
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Date of incident(*)
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Time of incident(*)
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Place of Incident(*)
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Supporting Information
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File Upload
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Details of Model

Type(*)
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Other
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Built From(*)
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other
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Wingspan - cm(*)
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Weight - kg(*)
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Engine Capacity/Thrust(*)
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Type of Model(*)
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e.g. Heli / Fixed Wing

Description(*)
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Power Plant(*)
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e.g. Electric / Internal Combustion (menthanol / petrol) / Gas Turbine

Construction Materials(*)
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Brand and Model Number Receiver(*)
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Brand and Model Number of Transmitter(*)
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Weather Conditions

Wind Strength(*)
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Cloud/Sun(*)
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Visibility(*)
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Wet/Dry(*)
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Number of flights that day prior to incident(*)
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Total flight time that day prior to incident
(in Minutes)(*)
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Brief Description(*)
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Radio Frequencies in use(*)
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Were the transmitter batteries charged prior to the first flight of the day?(*)
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Was a range check carried out prior to the first flight of the day and result?(*)
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Were the reciever batteries charged prior to the first flight of the day?(*)
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Primary Cause
Choose one. ...(*)
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Other Cause
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Secondary Causes (choose all relevant)
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Other Secondary Cause
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Post Incident and Prevention

What was the result of the post incident investigation of the model/s equipment?(*)
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Name of Submitter
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Position(*)
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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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