Injured Official Claim Form Request
Please complete the following form to start your insurance claim

Once your request has been reviewed you will receive a follow up email from DocUSign with a link to fill out and submit an online claim form for processing with our insurance carrier

Please Note: This form should be filled out only by the injured official

If you have any other questions please email Michael Komich secretary@nihoa.com

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Your Name *
Your E-Mail Address *
Chapter Name *
Date of Injury *
MM
/
DD
/
YYYY
Please provide a summary of your injury *
Do you have Primary Insurance Coverage *
Required
Are you fully registered with both NIHOA Nationally and your Local Chapter? *
Required
Can we assist with anything else today?
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