Participant Injury Incident Report Form
This form should be filled out and submitted when an incident or injury occurs that requires the following:
*Participant is recommended to/ visits medical facility
*Participant misses school/ work
*Any helmet damage or potential brain injury
*Any fractures, broken bones or lacerations requiring stitches

You must fill out, sign and FAX or Email: this form: to the Insurance Carrier ASAP. Customer support call 610.933.0800.

The Team Coach must sign the document.

Here is a link with information on how to file a claim:

The Accident Medical policy is excess over any other available insurance in regard to the injury. This policy will help cover reasonable and customary out of pocket medical expenses related to the injury such as deductibles and co-payments. The policy has an excess accident medical limit of $25,000 with a $250 deductible. The policy has a benefit period of 1 year from the date of the accident.

Email address
Date and Time of Incident
Your answer
Name of Club/Team
Your answer
Injured Person
Name of Injured Person
Your answer
Email of person legally responsible for injured
Parent's Name if a student is injured
Your answer
Cell Phone of Legally responsible
Parent's phone if student is injured
Your answer
Street Address
Your answer
City, Sate & Zip Code
Your answer
Age of Injured Person
Your answer
Sex of Injured Person
Affected Body Part
Primary injury or injuries
Describe the Injury
Your answer
On Site Care Given By
Choose all that apply
Care Provided on Site
Choose all that apply
Parent / Guardian Notified
Taken to Doctor / Hospital?
If yes, add location
Your answer
Name, Phone Number, Email of Two (2) Witnesses
Your answer
Name and Title of Person in Charge at Time of Incident
Your answer
Report Submitted By*
First and Last Name, Role
Your answer
Phone of Person Submitting Report
Your answer
Email of Person Submitting Report
Your answer
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