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Accident Details

Date of Incident

Date format should be mm/dd/yyyy

Date Incident Reported

Date format should be mm/dd/yyyy

Incident Organization Name 60 characters max

Address Line 1

Address Line 2

City

State

Zip Code

Zip Code 4

How did this incident occur?

Where did this incident occur?

Do any of these apply to this incident?

CPR, AEDs, or oxygen administered 911 or police called Facility closed or put on lock down Firearm or weapon involved Potential attorney involvement There has been a request for payment Damages will exceed deductible Allegation of abuse (sexual, physical, mental, verbal)

Please briefly describe the incident Note: 250 characters max 0/250 characters

Description of injury or damage Note: 250 characters max 0/250 characters

Was an adult/third party injured or involved in this incident?

Yes No

For example, is there someone who may make a claim (injury, property damage, etc.) who does not work for the organization?

Third-Party First Name

Third-Party Last Name

Third-Party Phone #

Third-Party Email

Date of Birth

Date format should be mm/dd/yyyy

Was a minor injured in this incident?

Yes No

Minor First Name

Minor Last Name

Minor Date of Birth

Date format should be mm/dd/yyyy

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone #

Incident Contact Info Same as Mine

Contact First Name

Contact Last Name

Contact Phone #

Contact Extension

Contact Email

(optional) Send a copy of this claim to: Separate multiple addresses with a comma. NOTE: You will automatically be sent a copy upon submittal

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