Incident Report Form

Note: All claims are to be filed within ONE month from date of incident

Personal particulars of person completing this report

Name

Membership no. / Identification no.

Contact no:

Email address

Please indicate if you are our: (choose one)

Keppel member **Guest (name of the Keppel member) Public golfer Staff

**If Guest, indicate name of the Keppel Member

Description of incident:

Nature of incident: (e.g. complaint, buggy incident, loss of equipment, disputes, etc)

Date of incident

Time of incident

Details of incident:
(state full details of incident, including any personal injuries, loss of personal belongings, damage to equipment / property, etc)

Particulars of witness or witnesses:

1. Name

Membership/Identification details

Contact no.

2. Name

Membership/Identification details

Contact no.

I declare the information provided above are true and valid

I agree to the Terms and Conditions and Privacy Policy