First Report Of Accident Form
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1AMERICAN SPECIALTY INSURANCE & RISK SERVICES, INC.
F
C
.C
AST
OV
OM
7609 W. JEFFERSON BLVD., SUITE 150
FORT WAYNE, IN 46804-4133
F
R
A
IRST
EPORT OF
CCIDENT
P
: 800.566.7941
F
: 260.969.4729
HONE
AX
DATE OF INCIDENT______________ TIME __________
AM
PM
DOES THE INJURED PERSON HAVE OTHER MEDICAL INSURANCE?
Team/Club/Organization:_____________________________________
Yes
No
If so, please provide:
Address:__________________________________________________
Name of Company:___________________________________________
Telephone Number:_________________________________________
Policy #:____________________________________________________
INJURED PERSON:
Athlete
Official
Coach
Spectator
DID THIS TAKE PLACE DURING:
Practice
Pre-Game
Employee
Volunteer
Other ________________________
During Game
Post-Game
While Traveling
________________________________________________________
Other _________________________________________________
INJURED PERSON INFORMATION
Last Name
First
Middle
Telephone Number (
)
Single
Married
Address
Social Security Number:_______________________________________
Employer Name:_____________________________________________
City
State
Zip
Address:___________________________________________________
Age
D.O.B.
Male
Female
___________________________________________________
GUARDIAN/PARENT (IF INJURED PERSON IS A MINOR)
Last Name
First
Middle
Telephone Number (
)
Address
City
State
Zip
INCIDENT LOCATION
INCIDENT
PRIMARY INJURY
Competition area
Concession area
Assault/Sexual
Slip/bodily reaction
Allergy
Dislocation
Nausea
Parking lot
Admission area
Assault/Non-Sexual
Slip/Fall
Amputation
Cardiac
Stroke
Restrooms
Off property
Fall (different level)
Aquatic
Abrasion
Foreign Body
Burn
Locker rooms
Store area
Caught in/on/between
Overexertion
Laceration
Fracture
Death
Premises/grounds
Collision (with object)
Animal/insect bite/
Drowning
Cardiac
Pain
Bleachers/stands
Struck by falling/flying
sting
Sting/bite
Contusion
Illness
object
Cold Injury
Concussion
Seizures
Collision (participant/participant)
Hypertension
Tooth/Mouth
Collision (participant/spectator)
Strain/Sprain
Electric Shock
Collision (spectator/spectator)
BODY PART INJURED
DISPOSITION
CLASSIFICATION
Eye - L or R
Torso
Arm - L or R
Released to parent
Police
Non-Injury
Nose
Back
Tooth
Refusal of care
Ambulance
Minor injury or illness
Neck
Face
Head
Refer to doctor
Report only
Serious injury or illness
Ear - L or R
Leg - L or R
Refer to hospital or clinic
Knee - L or R
Ankle - L or R
Medical attention
Internal
Hip - L or R
EMS transport
Shoulder - L or R
Foot - L or R
Patient requested EMS transport
Elbow - L or R
Hand - L or R
Released to personal vehicle
Wrist - L or R
Finger or Toe
DESCRIBE HOW THE INCIDENT OCCURRED: (attach a separate sheet if necessary)
WITNESS INFORMATION
NAME
ADDRESS
TELEPHONE NUMBER
1.
(
)
2.
(
)
S
P
C
F
:
D
IGNATURE OF
ERSON
OMPLETING
ORM
ATE
___________________________________________________
__________________
P
N
P
: ____________________________
RINTED
AME
HONE
:__________________________________________________________
INCIDENT REPORT FORM
UPDATED: JANUARY 2015
SP 6163505
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Parent category: Medical