Claimant Information 1. Name of Injured Party DOB Employee Client Volunteer Visitor Other -- Address -- Street City State Zip Home Phone # Business Phone # Email Address ( ) ( ) Description of Injury (nature and extent of; please be specific): Transported by Name and Phone # of Hospital or Doctor, if applicable Ambulance Yes No Observations of Nonprofit of Clothing (i.e., shorts, t-shirt) Type of Shoes Was Claimant carrying anything? (if Claimant’s Attire/Description yes, what) No Yes -- the report (i.e., agitated, in obvious or no obvious pain, able to move around while Describe claimant’s demeanor when making describing what happened, etc.) Claimant (use the back of the form or attach an additional sheet of paper if needed) Information 2. Name of Injured Party DOB Employee Client Volunteer Visitor Other -- Address -- Street City State Zip Home Phone # Business Phone # Email Address ( ) ( ) Description of Injury (nature and extent of; please be specific): Transported by Name and Phone # of Hospital or Doctor, if applicable Ambulance Yes No Observations of Nonprofit of Clothing (i.e., shorts, t-shirt) Type of Shoes Was Claimant carrying anything? (if Claimant’s Attire/Description yes, what) No Yes -- the report (i.e., agitated, in obvious or no obvious pain, able to move around while Describe claimant’s demeanor when making describing what happened, etc.) (use the back of the form or attach an additional sheet of paper if needed) PRINT NAME OF INDIVIDUAL COMPLETING THE FORM SIGNATURE DATE
Claimant Information 1. Name of Injured Party DOB Employee Client Volunteer Visitor Other -- Address -- Street City State Zip Home Phone # Business Phone # Email Address ( ) ( ) Description of Injury (nature and extent of; please be specific): Transported by Ambulance Yes No Name and Phone # of Hospital or Doctor, if applicable Observations of Nonprofit Claimant’s Attire/Description of Clothing (i.e., shorts, t-shirt) Type of Shoes Was Claimant carrying anything? (if yes, what) No Yes -- Describe claimant’s demeanor when making the report (i.e., agitated, in obvious or no obvious pain, able to move around while describing what happened, etc.) Claimant Information (use the back of the form or attach an additional sheet of paper if needed) 2. Name of Injured Party DOB Employee Client Volunteer Visitor Other -- Address -- Street City State Zip Home Phone # Business Phone # Email Address ( ) ( ) Description of Injury (nature and extent of; please be specific): Transported by Ambulance Yes No Name and Phone # of Hospital or Doctor, if applicable Observations of Nonprofit Claimant’s Attire/Description of Clothing (i.e., shorts, t-shirt) Type of Shoes Was Claimant carrying anything? (if yes, what) No Yes -- Describe claimant’s demeanor when making the report (i.e., agitated, in obvious or no obvious pain, able to move around while describing what happened, etc.) (use the back of the form or attach an additional sheet of paper if needed) PRINT NAME OF INDIVIDUAL COMPLETING THE FORM SIGNATURE DATE
Accident%20Claim%20Form.docx