WHEN, WHERE, WHY & HOW IT HAPPENED

Please read the instructions.

This form is to be filed out when an accident or injury occurs that could potentially result in a claim against the insurance, whether or not you know there is a claim. Please complete this form within 48 hours of the accident. When the insurance company receives this form, they will send you a claim form.

When you submit this form, I will generate a PDF file that you can view with the Acrobat Reader. You should look this form over before it gets submitted to the insurance chairman. The "Preview" button will do that: it shows you a copy of the form, WITHOUT sending it. When you are finally happy with the form, use the "Submit" button instead.

When you click "Submit", a copy will be sent by email to the Federation insurance chairman. If you check the box below, a copy will be e-mailed to you as well.

Club Officer Contact Person
Association:	Oregon Federation of Square & Round Dance Clubs
Council:
Club Name:
Club Officer Name:
Club Officer Phone:
Injured Party
Accident Date:
Accident Location:
Injured Person:
Their Address:
Their City:
Their State:
Their Zip:
Their Club:
Accident Information
Nature of Injury:
Reported?	Check if the accident was reported to the facility where the accident occured.
Describe Accident:
When & Where Was Treatment Given:
Witness Information
Witness 1 Name:
Witness 1 Address:
Witness 2 Name:
Witness 2 Address:
Witness 3 Name:
Witness 3 Address:
Your Information
Your Name:
Your Phone Number:
E-mail:	Please e-mail a copy of this form to me.