Basketball Manitoba Accident Insurance Initial Claim
Please complete this form to begin your insurance claim through Basketball Manitoba. All information collected will be kept in strict confidence as detailed in Basketball Manitoba's Privacy Policy. https://www.basketballmanitoba.ca/2013/01/basketball-manitoba-privacy-policy.html
Full Name of Injured Person *
First and Last
Date of Birth of Injured Person *
MM
/
DD
/
YYYY
Parent / Guardian Full Name
Only complete if the injured person is under the age of 18 at the time of the accident.
Email Address *
For youth aged claims (under the age of 18 at the time of the accident), please use a parent or guardian's email address. All correspondence will be made using this email address.
Daytime Phone Number *
Include the area code. No spaces or special characters.
Next
Never submit passwords through Google Forms.
This form was created inside of Basketball Manitoba. Report Abuse