Product Liability Accusation Form

Product Liability Accusation Form
Use this form to report an alleged product-related defect, failure, or incident and provide the details needed to review the accusation.
Complainant Information
Full Name
First NameMiddle NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
Product Identification
Product Name
Brand or Manufacturer
Model Number or SKU
Product Category
Serial or Lot Number
Place of Purchase
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Purchase Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Incident and Liability Details
Date of Incident
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Incident
Hour Minutes
AM/PM Option
Location of Incident
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
How Was the Product Being Used?
Detailed Description of What Happened
Alleged Defect, Failure, or Malfunction
Was the Product Modified or Repaired Before the Incident?
Was Anyone Injured or Was Any Property Damaged?
Impact and Supporting Information
Describe any injuries or harm caused
Did you seek medical attention?
Describe any property damage
Witnesses and contact details
Upload evidence files
Cancelof
Requested resolution
Additional notes
Should be Empty: