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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
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* Indicates required question
Full Name of Injured Person
*
First and Last
Your answer
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.
Your answer
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.
Your answer
Daytime Phone Number
*
Include the area code. No spaces or special characters.
Your answer
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