Fillable Accident/Incident Witness Statement This form should be completed (Girlguiding UK)

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Accident/Incident Witness Statement This form should be completed (Girlguiding UK)

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Accident/Incident
Witness Statement
This form should be completed by any person who has witnessed an accident or incident involving
Girlguiding members. This information will aid in the investigation of the incident and therefore
should be completed as soon as possible after the event. Please submit this form, together with
all relevant Notication of Accident/Incident forms, to Insurance Department, Girlguiding,
17–19 Buckingham Palace Road, London SW1W 0PT.
Name of witness: _____________________________________________________________________
Membership number (if applicable): ______________________ DOB:_________________________
Address: _____________________________________________________________________________
___________________________________________________________________________________
Name of unit and/or event: ____________________________________________________________
County: ____________________________________________________________________________
Country/Region: ______________________________________________________________________
Time of accident/incident: ________________ Date of accident/incident: _______________________
D a t e f o r m c o m p l e t e d : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________________________________________________________________ _
(Please provide statement overleaf)
Statement
Please include full details of the accident/incident, including photos, lm and the names of
those involved and any other details you think may be relevant or useful to any investigation.
Signed ______________________________________________________________________________
We collect your personal information to provide incident related support, process insurance claims and other
legal purposes.
We may share your data with:
• Insurance companies
• Legal representatives
We process the data you provide under our legitimate interests of managing insurance on behalf of our membership.
For further information on how and why Girlguiding use your personal data, including how long we keep it, your rights,
and how you can contact us, please read our full privacy notice at: girlguiding.org.uk/privacy-policy/
December 2019
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AccidentIncident Witness Statement This form should be completed (Girlguiding UK)

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Completed 25 November 2020

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