CUSTOMER INCIDENT REPORT

This form should be used to report any incidents involving customers and employees
such as slipping and falling in the restaurant, finding a foreign object in food, biting into
an object in food.
Please follow these procedures as closely as possible.
1. Fill out as much information as possible. If the person cannot respond, please try to
get the information from whoever is with the person.
2. If requested, give the customer the name of our insurance carrier, policy number, and
broker as follows:
CARRIER: Oregon Mutual Insurance Co
BROKER: ARGO Insurance, Inc.
Tom Stavrikas (714)701-0668
3. If necessary, let the customer know that someone will contact them on the next
business day. Be sure to get the phone number where they can be reached.
4. If a serious accident or injury occurs in the restaurant, notify your district manager or
the general manager immediately. PLEASE WRITE LEGIBLY.
CUSTOMER NAME: _______________________________________________
ADDRESS: ______________________________________________________
TELEPHONE: ____________________________________________________
Date of Incident: _________________Time of incident: _________________
Description of what happened: _____________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Is the customer expecting a call from the main office? Yes ____No____
Witnesses: ______________________________________________________
List any employees involved with the customer or any employees who may have
witnessed the incident and cook if foreign object found in food.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Circle cameras which show incident.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Was the customer eating here or to go. ________ Where was the customer sitting.
______________________________________________________________________
Fax back to corporate office immediately (323)887-7171.

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