SECURE INCIDENT INTAKE

Report an incident

Complete this form as soon as practical. You can attach photos or PDFs and sign from a phone, tablet, or computer.

Emergency? Call 911 first. This form does not contact emergency services.

1Restaurant information

Restaurant # type or chooseLoading active restaurants… City / State Report prepared by

2Potential claim / incident type

Select every option that applies.

3Required follow-up

Was medical attention necessary?

If yes for an employee, a Workers' Compensation report is also required.

YesNo

Can the cost be recovered from another individual?

YesNoUnknown

Was the total property loss over $2,500?

YesNoN/A

4Incident details

Date of incidentTimePerson involved Camera # optionalCamera time optionalExact place where incident occurred Part of building / areaBody part affected if applicable

5What happenedDescribe exactly how the incident happenedWhy did it happen? Include known or suspected contributing factors.

6Corrective actionImmediate action takenAdditional corrective action / prevention plan optional

7Witnesses and managerWitness name(s) and contact information optional

Store Manager optionalManager initials optional

8Photos and documents

Add up to 8 JPG, PNG, HEIC, or PDF files. Each file must be 8 MB or smaller; combined files must be 24 MB or smaller.

Choose photos or PDFs

9Contact, attestation, and signature

Your full nameEmail addressPhone number optional

I confirm that the information in this report is true and complete to the best of my knowledge. I understand that GRO Restaurant Group may contact me for additional information.Attestation version:

Draw your signatureUse a finger, mouse, or stylus.

I cannot draw a signature. Use my typed full name above as my electronic signature.

Ready to submit?

A signed PDF copy will be stored securely. Nathan will receive a review notice, and the claims mailbox will receive a report copy.

Report an incident

Thank you. Your incident report was submitted.