Risk Management—Kingdom Hall Assistance Arrangement (T-5) (1998)
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Witnesses
Ask any witnesses to the accident to describe what happened. Have two brothers present to document the comments, questions, and answers. No one is obligated to answer these questions. The following questions should be asked: 1 What were you doing when the accident occurred? 2. Did you see the accident? 3. According to your understanding, what happened? ( Please do not ask any other questions; specifically, do not discuss who or what may have been at fault, the cause of the accident, or reference to any legal action.)
Name:
(Phone Number)
Address:
(Street)
(City)
(State)(ZIP)
Name:
(Phone Number)
Address:
(Street)
(City)
(State)(ZIP)
Other Individuals who may have helpful information
Name:
(Phone Number)
Address:
(Street)
(City)
(State)
(ZIP)
Coordinating Elder
Name:
(Phone Number)
Address:
(Street)
(City)
(State)(ZIP)
(Cong. Name)
(City)
(State)(Cong. No.)
If a citation was issued for the violation of any ordinance or statute, please enclose a copy of the citation. If an investigation was conducted by a third party (i.e. Police, Insurance Company, Attorney, etc...) please provide us with a copy of their report along with the name, address, and telephone number of the person conducting the investigation.
Signature of Presiding Overseer
Date Completed
Return completed form along with copies of citations, investigation reports,and/or eyewitness accounts of the accident (if applicable) to:
Watchtower Attn: Risk Management 25 Columbia Heights Brooklyn, NY 11201-2483 ACCIDENT REPORT
Information about the Injured Person
(If the injured person is unavailable to answer questions, please complete this information to the best of your knowledge)
Name:
Address:
(Street)
(City)
(State)
(Zip)
Age:
Male
Female
Baptized
Elder
Ministerial Servant
Pioneer
Other
Occupation:
Employer:
Health Insurance
Name of Insurance Company:
Location of Accident
Address:
(Street)
(City)
(State)
(Zip)
Date of Accident:
Time of Accident:
Activity when Accident Occurred:
Description of Injury
For Description of Injury and Injured Person's Account sections: Ask the injured party what happened. Have two brothers present while documenting the comments, questions, and answers. The following questions should be asked. 1. What were you doing when the accident occurred? 2. How did the accident happen? 3. What injury did you suffer?
How was it treated? Doctor's Office Hospital Outpatient Hospital Inpatient
Injured Person's Account
Please describe how the accident occurred, including all contributing factors.
Please attach a diagram on letter-size paper of the location describing where the injury occurred.
Please attach photographs of the location of the accident, showing the arrangement of items at the time of the accident. Please indicate if the photographs are of the scene shortly after the accident, or if some time has passed and this is a reconstruction of the accident site.
PROPERTY LOSS REPORT
Congregation Number:
Date Loss Occurred:
Congregation Name:
(Name)
(City)
(State)
Loss Information
☐ Burglary
☐ Fire
☐ Glass
☐ Vandalism
☐ Vehicle
☐ Windstorm/Hail
☐ Water Damage
☐ Other
Has Regional Building Committee been contacted to provide skilled workers, if necessary? ☐ Yes ☐ No
Property Damaged: (List each item, giving the cost to repair. Please attach written estimates or bills for each.)
Property Stolen: (List each item, giving the cost to replace. Please attach written estimates or bills for each.)
TOTAL AMOUNT OF CLAIM: $ (Must equal total of attached estimates and bills.)
If burglary, vandalism, or vehicle damage, please report to the police and attach a copy of their report. Also, if it was a burglary, please send details of what loss control measures have been taken or planned to minimize the chance of reoccurrence.
Is identity of one responsible for damage known to you or the police? ☐ Yes ☐ No
Name and phone number of two elders who may be contacted during business hours:
(Name)
(Name)
(Phone)
(Phone)
(Date completed)
(Signature of Presiding Overseer)
LOSS CONTROL CHECKLIST
Name of Congregation: ___
Street Address: ___
State:___
City: ___
FIRE PROTECTION
Zip Code: ___
Congregation No.: ___
b. Tagged with date of last service?
Date last serviced ___
c. Easily accessible?
d. Hung within 75' of any part of each floor depending on size, in a conspicuous place?
e. Not subject to freezing if water or soda acid?
Are periodic tests and inspections made of the following to insure proper operation:
a. Fire hoses Date tested ___
b. Automatic sprinkler system Date tested ___
c. Fire alarm system Date tested ___
STAIRS AND DOORS
a. Stairs covered with anti-slip surfaces?
b. All handrails securely fastened?
HOUSEKEEPING
Are waste receptacles provided and are they emptied regularly?
Are storage and supply rooms neat and orderly?
Are flammable paints and liquids:
a. Kept to an absolute minimum?
b. Kept in sealed metal containers?
c. Stored in approved flammable liquids storage cabinets?
Are only non-flammable cleaning materials used?
Are all closets free of oily mops and flammable materials?
c. Hallway doors kept closed when not in use?
d. Full length clean glass doors and windows marked to avoid someone's walking into them?
*N/A-Does not apply
YES
NO
N/A*
HOUSEKEEPING(contd)
YES
NO
N/A*
Is the building locked when there is no one on the premises?
Is attic free of flammable materials?
EXITS AND ACCESS
Are all exits visible and unobstructed?
Are all exits marked with a readily visible sign that is properly illuminated?
Are all exit doors:
a. Arranged to open outwards?
b. Easily operated?
c. Provided with anti-panic hardware in all public rooms and areas?
Are all fire escapes in good condition?
Are there any holes or cracks in sidewalks or parking lots?
Will they be filled?
SIDEWALKS AND PARKING AREAS
Are all areas free of conditions which will cause slipping and falling?
Is there adequate exterior lighting at night?
Are all steps and ramps provided with securely fastened handrails?
LIGHT, POWER, HEAT, AND APPLIANCES
Is all heating equipment (incl. flues and pipes):
a. Properly insulated from combustible materials?
b. Cleaned and serviced annually by a competent heating contractor?
Are electrical, heating, and A/C rooms:
a. Restricted to authorized personnel only?
b. Free of combustible storage?
Are electrical extension and appliance cords in good condition?
Has the electrical system been checked and serviced by a competent electrician within the past five years?
Date of last inspection
LIGHT, POWER, HEAT, AND APPLIANCES (contd)
YES
NO
N/A*
Is air-conditioning equipment cleaned and serviced by a competent serviceman?
\Box
\Box
\Box
Date serviced
Are motors kept clean and adequately ventilated to reduce overheating?
\Box
\Box
\Box
Are all electrical appliances properly grounded?
\Box
\Box
\Box
Are furnace rooms and boiler rooms free of flammable material?
\Box
\Box
\Box
Are furnace rooms and boiler rooms free of lawn mowers and gasoline cans?
\Box
\Box
\Box
MONEY
Are money collections deposited the same day in a night bank depository? Are residents in the immediate area and local police asked to keep an eye out for suspicious activities?
KITCHEN
YES
NO
N/A*
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Are hood, ducts, ovens, ranges, and filters cleaned on a regular basis? Is the automatic fire extinguishing system inspected and maintained by contract?
FIRST AID
Is only the minimal emergency first aid and treatment administered? No medications kept at this location?
Signature and phone numbers of operating committee
Date completed: ___
(Please complete and return to the Society)