Athletic Accident Claim Form - Sbc Insurance
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4ATHLETIC ACCIDENT CLAIM FORM
SECTION I
(please print)
Last Name of Claimant
First Name
Birth Date
Mailing Address
Suite 302, 1901 Rosser Avenue
City
Province
Postal Code
Burnaby, BC V5C 6R6
Phone 604-737-3008
If a Minor, Name of Parent
Toll free 877-992-2288
Fax 604-737-3076
Home Phone
Business Phone
Email:
(
)
(
)
SECTION II
Date of Accident
Hour
a.m. / p.m. (circle one)
Location of Accident
What is the injury?
Date of First Treatment
Name of Hospital taken to
Date of Admittance
Hour
a.m. / p.m. (circle one)
Date of Discharge
Name of Attending Physician or Dentist
SECTION III
Describe fully how the accident happened.
SECTION IV
(your sport accident policy is an excess accident benefits policy; proof of exhausting all other insurance must accompany your expenses)
What medical coverage do you have through your/spouse/parent employment?
Name of Employer
Name of Insurer
Address of Employer
Address of Insurer
City
Prov.
Postal Code
Policy No.
Certificate Number
SECTION V
CERTIFICATION OF ASSOCIATION OR CLUB EXECUTIVE
I hereby certify that all the information provided above
Do not complete this section yourself; have your Club or
is correct.
League President, Coach or Manager complete this section.
Claimant’s / Guardian’s Signature
Date
Name of Team
League or Association
Send completed form along with any invoices for expenses
Accident Policy No.
Type of Sport
you incurred to -
By mail:
Was the above player registered at the time of the injury?
Allsport Insurance Marketing Ltd.
Yes/No (circle one)
Suite 302, 1901 Rosser Avenue, Burnaby, BC V5C 6R6
Was the player injured while taking part in an authorized activity?
By fax:
Yes/No (circle one)
604-737-3076
By email:
Name
Position with Club
Telephone No.
Signature
Please call Allsport if you have any questions regarding this
form. Instructions are on the reverse side. If you do not have
invoices at this time, please forward the form only to confirm
that you intend to make a claim.
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