Accident Claim Form - Ringette Alberta Page 2
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1
2PHYSICIAN’S STATEMENT
_________________________________________________________ ______
Name of Patient:
____________________________________________________
Full description of injury sustained:
____________________________________________________________________________
_________________
________________
Date of First Attendance (M/D/Y):
Date of Actual Loss (M/D/Y):
____________________________________
Is loss permanent and irrecoverable? Give degree of loss:
___________________________________________________________________________
Is condition direct result of an accident?
Yes
No
_____________
_
Did any disease or previous injury contribute to loss?
Yes
No If yes, describe:
____________________________________________________________
____________
_____ ____________
Was Patient hospitalized?
Yes
No If yes, give Hospital Name and Address:
_________________________________________________________________________ _
Names and Addresses of other Physicians or Surgeons, if any, who attended Patient:
___________________________________________________________________________
___________________________________________________________________________
Are you related to or in a business relationship with this patient?
Yes
No
These statements are true and complete to the best of my knowledge and belief.
_____________________________________________
Name of Attending Physician (please print) :
_____________________________________________________________________
Address :
______________________
_____________________
Signature of Attending Physician :
Date (M/D/Y) :
__________________________________
_____________________
Phone Number :
Fax Number:
ASSOCIATION STATEMENT
_____________________________
Name of Club:
Name of Individual:
The Individual is:
Member
Volunteer
Was the individual a member or volunteer on the date of the accident?
Yes
No
Did the injury occur while Insured was participating in an activity recognized by the Association?
Yes
No
Please attach a copy of your incident report related to this event (if available).
______________________________________
_____________________
Signature :
Date (M/D/Y) :
_________________________
_____________
Title :
Phone Number:
Email:
The furnishing of forms shall not be an admission of liability by the Company.
Claimant’s Statement – Accident Claim Form (**Please ensure that Page 2 is completed)
2 of 2
Revised – 10/05/2013
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