Lycetts Incident Notification Form

1. Full Name of Insured (If a business name, please give the owner(s) full name(s)):*

b. Email

c. Telephone No(s)

2. Please provide full details of any other Liability Insurance you may have

3. Name of the complainant(s)*

a. Age - if under 18

c. Any other contact details

4. Date of Incident

6. Weather Conditions

7. Approximate width of road at point of impact (if relevant)

8. Type of road surface at point of impact (if relevant)

9. Who owns and/or has responsibility for the land where the incident occurred?

10. Details of and INJURIES and/or DAMAGE caused (however slight)

11. Were there any witnesses to the incident? If so, please provide their name(s), address(es) and daytime telephone number(s)

12. Has the incident been reported to the police? If so, please provide the name and address of officer and/or station and police report number

13. Please provide the name, breed, height, sex and age of the horse(s) involved in the incident

14. Please provide the name(s) and address(es) of the owner(s) of the horse(s) involved in the incident

If 'Yes', please give full details

16. If YOU own the horse(s), how long have you owned it?

17. Describe the horse's general temperament

18. How often is the horse ridden/exercised and when was the last occasion prior to the incident?

19. How often is the horse(s) turned out into the field and when was the last occasion prior to the incident?

20. In what activity was the horse(s) engaged when the incident occured?

21. Please describe how the horse(s) behaved prior to, during and after the incident

22. What do you think caused the horse(s) to behave as it did?

If 'Yes', please provide: name, age, address and daytime telephone number of the person(s) involved riding/handling them?

a. Does this person ride or handle the horse(s) regularly? If so, please describe their relationship to you and in what capacity they were involved

If 'Yes' to (b) or (c), please provide the name and address of the insurer and the policy number

24. If the horse(s) escaped, please provide details of the height, type and conditions of fencing and gate security.

a. Do you own/rent the land?

b. Who has responsibility for maintenance of the land and fencing?

c. How regularly is the fencing inspected?

d. Do you have any risk assessments in place regarding the inspection of the fencing? If yes, please give a brief description

e. Has there been any previous incidents of horse(s) escaping?

If 'Yes', please provide full details

If 'Yes', please provide details

Name of person who completed the form

Incident Notification