Section 1 of 2
DECLARATION D'ACCIDENT
Ce formulaire est destiné aux membres qui ont eu un accident
1. Remplir le formulaire ci-dessous. Il arrivera directement chez moi
2. Me transmettre le certificat médical (Annexe D) ICI
3. Me transmettre l'attestation mutuelle en y collant une vignette (Annexe C) ICI
Ces deux annexes doivent me parvenir via mon adresse mail : secretaire@volleygembloux.be
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Nom et Prénom
Nom et Prénom
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Date de naissance
Date de naissance
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Numéro de licence
Numéro de licence
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Adresse complète (Rue, N°, Code postal, ville)
Adresse complète (Rue, N°, Code postal, ville)
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Adresse mail
Adresse mail
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N° de téléphone et/ou GSM
N° de téléphone et/ou GSM
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Date de l'accident
Date de l'accident
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Heure de l'accident
Heure de l'accident
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Description de l'accident
Description de l'accident
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Quelle(s) est/sont la(es) lésion(s) constatées
Quelle(s) est/sont la(es) lésion(s) constatées
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Etes-vous titulaire de votre mutuelle ?
Etes-vous titulaire de votre mutuelle ?
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OUI
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Section 2 of 2
Titulaire de la mutuelle
Si vous n'êtes pas titulaire de votre propre mutuelle, veuillez compléter la suite...
Nom et prénom du titulaire
Nom et prénom du titulaire
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Adresse complète si différente de l'accidenté
Adresse complète si différente de l'accidenté
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Adresse mail
Adresse mail
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N° de téléphone et/ou GSM
N° de téléphone et/ou GSM
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