Incident/ Injury Report Form
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1INCIDENT/INJURY FORM
DATE: ___________________ EVENT: ____________________________________________ MCC UNIT #: ______________
DATE OF INCIDENT: ____________________ SPECIAL EVENTS INSURANCE COVERAGE: YES _______ NO _______
PARISH/INSTITUTION: __________________________________________________ CALLER: _________________________
ADDRESS: _____________________________________________________________ PHONE: _________________________
CITY: _________________________________________________________________ PASTOR: _________________________
INJURED PERSON: _____________________________________________________
PHONE: _________________________
ADDRESS: ___________________________________________
CITY: ________________________ ZIP: _______________
SOCIAL SECURITY NO.: _________-________-___________
DATE OF BIRTH: ________ / ________ / ________
INJURED PERSON DATA (Age, sex, marital status, employment, etc.): _________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
DESCRIPTION OF INCIDENT: _________________________________________________________________________________
____________________________________________________________________________________________________________
INJURIES: __________________________________________________________________________________________________
____________________________________________________________________________________________________________
MEDICAL TREATMENT (Where, when, etc.): _____________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
MEDICAL INSURANCE: ______________________________________________________________________________________
WITNESS INFORMATION:
NAME: _____________________________ ADDRESS: ______________________________________ PHONE: _______________
NAME: _____________________________ ADDRESS: ______________________________________ PHONE: _______________
DATA PERTINENT TO INCIDENT/INJURY: _____________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
SIGNATURE OF INJURED PERSON: ___________________________________________
DATE: _____________________
PLEASE REPORT ALL INJURIES IMMEDIATELY BY PHONE TO GALLAGHER BASSETT INSURANCE SERVICES:
2601 CAMBRIDGE COURT SUITE 435
AUBURN HILLS MI 48326
(248) 452-6050 FAX (248) 475-0228
RM: 03/12
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Parent category: Medical