Sport Accident Claim Form printable pdf download

SPORT ACCIDENT CLAIM FORM

Full name of Insured Person (member) ______________________________________________

Date of Birth (mm/dd/yyyy) _____________________ Male / Female _____________________

Mailing Address including City and Postal Code _______________________________________

_____________________________________________________________________________

Contact Person if claimant is a minor (parent or guardian) _______________________________

Home Phone _______________________ Daytime Phone Number: _____________________

Email address ____________________________________________

Date of Accident _______________________________________________________________

Location of Accident ____________________________________________________________

Describe in detail how the accident occurred _______________________________________

______________________________________________________________________________

Type of Injury ___________________________________________________________________

Name of Doctor/Dentist ___________________________________________________________

Address of Doctor/Dentist _________________________________________________________

Do you have other benefits provided under any other insurance plan? ________________________

If yes, please provide name of Insurer and policy number (certificate) _________________________

________________________________________________________________________________

I hereby certify that all information provided in this accident form is correct.

Claimant/Guardian signature _________________________________Date ___________________

Certificate of Team Manager / Association or Club Executive:

Name of Team/Club/ League/Association _______________________________________________

Policy Number ___________________ Was the player a member at the time of the accident? _____

Was the injury during a sanctioned game or practice? ________________

Name ______________________________________ Position ______________________________

Signature ___________________________________ Phone number _________________________

Date ______________________________________

See Instruction Page for further details on submitting claims

1/3

Sport Accident Claim Form