The Kades Corporation

Customer Incident Report

Owners Name	Company Name	Date Reported
Incident Report By Title	Phone No	Policy No
Store No	Address	Date Of Occurence,Including Time
Store Manager	Store Manager On Duty	Store Phone No

Name	Sex	DOB
Age	If Minor, Name Of Parent Or Gardian	Home Phone No
Address,City,State		Business Phone No
Description Of Incident		Cell Phone Or Pager Number


Has Injured Person Received Medical Treatment? If Yes, Where?		Phone No Of Treatment Center
If foreign object involved, object retained by Insured or Customer? ( If retained by the Insured. please mail Immediately to CNA by certified mail. Must include confirmation# assigned by CNA.)
Product Supplier	Phone Number For Supplier	Product box Code No
Describe Customer's Property Damage,Including Amount	Where can property be seen?	When?
Clamints's Attorney Name:	Address,city,State	Phone Number

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