DIHAC

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Premises Liability

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Did you slip (or trip) and fall within the last 3 years?

Did you suffer an injury as a result of your fall?

Did you fall on public or private property?

If you fell on public property, please indicate one of the following:

Which of the following best describes your relationship to the property?

Did you slip on a weather related condition, such as ice, rain, or snow?

Did you slip (or trip) on a crack, pothole or uneven surface?

Did you see the defect, condition, or substance BEFORE you fell?

Did you report the incident to the property owner, agent or representative following the incident?

Was the incident investigated?

Was the property insured?

Were you treated or evaluated by a physician within 24 hours of the incident?

Have you been seen by a doctor or medical care facility since the incident?

Have you undergone surgery, or, has any doctor recommended surgery as a result of your fall?

Have you missed time from work?

Do you have one of the following health care coverages?

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