Basketball Manitoba Accident Insurance Initial Claim

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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 *

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.

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This form was created inside of Basketball Manitoba.