Lost & Incedent Report Form

Loss & Incident Report                

Claim No. 

Report No                               

Please use this form to report all injury and security incidents whether they involve the hotel, its employees, its guests, or any asset, to Golden Tulip Hotel Group.

General Liability  ☐                            Hotel Property  ☐                             Hotel Crime ☐

Hotel Name :		Location No.
Street Address :
City :		State/ Province/ Country :
Postal Code :		Phone No :
General Manager :		E-mail Address :
Name of person involved :
Was person involved a hotel guest, invitee, vendor or other?
Street Address：
City	State/ Province/ Country:					Postal Code:
Date of Birth :		Gender :
Home Phone No		Work Phone No.:
Check-in Date :		Check-out Date :
Room No .:		Is this person making a claim  :  Yes  ☐   No ☐
Date of Incident :		Time of Incident :
Location of incident (Where on the property?) :
Type of Incident (Slip/Fall, Room Theft, Illness, etc.）:
Cause of Incident :
Did an injury occur :   Yes  ☐       No   ☐      N/A   ☐
Description of incident:  1) Give detailed information; 2) Describe what occurred (when, where, by whom and how);
Identify all involved and list all witnesses and their addresses; 4) If theft, list estimated value and description of item.
Action taken by hotel :
Amount of property loss/ damage (estimate):
Medical assistance rendered by hotel :			Yes ☐    No  ☐    N/A  ☐
Police or Fire department contacted :			Yes  ☐    No  ☐    N/A  ☐      Report No :
Information was reported to (Name of employee):					Position :
Information was reported by (guest, employee, etc.):
Was car valet parked?			Yes ☐    No  ☐    N/A   ☐
Were liability signs posted?			Yes ☐    No ☐    N/A   ☐
Were there signs of forced entry?			Describe :
Were locks interrogated? (Attach Report)			Yes  ☐    No   ☐    N/A   ☐
Results of interrogation :
Was housekeeping questioned?			Yes  ☐    No   ☐    N/A  ☐
Results of questioning
Witness name :				Phone no.
Address :
Witness name :				Phone no.
Address :
Comments :
Report Completed By:				Title :
Date of Report :			Report Reviewed by GM   Yes   ☐    No     ☐    N/A    ☐