(602) 840-3234
About
Our Company
Swimming Insurance Program
Sports Teams & Leagues
General Liability
Participant Accident
Sports Instructor
Not for Profit Directors and Officers/Crime
Property
Special Event Coverage
Sample Forms & FAQs
The Risk People
Contact Us
(602) 840-3234
CLAIMS
REPORT OF OCCURRENCE
Please Indicate Your Affiliation
(Required)
Please Indicate Participant or Spectator
Club Name
INJURED PERSON’S INFORMATION
Name*
(Required)
Age
Participant’s parent name
(Required)
Email
Phone participant’s parent name
Address
City
State
Zip
Club Affiliation
ACCIDENT INFORMATION
Activity Taking Place at Time of Accident
Place Where Accident Occurred (Include City/State)
Date of Accident
MM slash DD slash YYYY
Description of Accident
PERSON IN CHARGE INFORMATION
Name*
(Required)
Address
City
State
Zip
Phone
ADDITIONAL INCIDENT INFORMATION
Nature of Injury
Who Determined the Nature of Injury (Coach, medic, fire, etc.)
What Was Done On-Site for Injured Person
Location Treatment was Administered (facility, ER, Urgent Care, etc.)
Who Provided Treatment (Name)
Witness 1
Witness 2
Witness 3 Remarks
REPORT WRITER’S INFORMATION
Name*
(Required)
Date of Report
MM slash DD slash YYYY
Address
City
State
Zip
Phone
Contact Email*
(Required)
ADDITIONAL DOCUMENTATION
Please attach any additional accident reports (facility report, newspaper, witnesses’ statements).
Drop files here or
Select files
Max. file size: 10 MB.
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