File A Claim - Risk Management Services

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)

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

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

Address

City

State

Zip

Phone

Contact Email*(Required)

ADDITIONAL DOCUMENTATION

Please attach any additional accident reports (facility report, newspaper, witnesses’ statements).

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AUDIT – ADDITIONAL PARTICIPANTS

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CLAIMS

REPORT OF OCCURRENCE

INJURED PERSON’S INFORMATION

ACCIDENT INFORMATION

PERSON IN CHARGE INFORMATION

ADDITIONAL INCIDENT INFORMATION

REPORT WRITER’S INFORMATION

ADDITIONAL DOCUMENTATION