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Incident Report Form

Claims Reporting Procedure

If you have a question concerning whether to report an incident or claim, call your broker.

NONPROFIT / INSURED – Complete all items to the best of your ability, sign and date page 2, and immediately give it to your supervisor.
Supervisor – Fax this Incident Report Form to your insurance broker immediately.
- Important: Retain any equipment or furniture which caused or contributed to an injury until it can be inspected by an insurance representative.
BROKER– Refer to our website for instructions on claim reporting.

If a claim needs to be reported after business hours or on the weekend, call (866) 718-1947. This number is reserved for true claims emergencies after business hours and weekends.

General Information

Name of Nonprofit Organization	ANI/NIAC Policy Number
Name of Contact	Title
Nonprofit Address – Street, City, State, Zip
Business Phone #	Business Fax #	E-mail Address

Incident Information

Date of Incident	Day of Week	Time of Incident	Did the incident occur on organization’s premises?
Location of Incident (if possible, take pictures of the area with a digital or disposable camera)
Description of Incident (A brief factual account of the incident; include who was involved, how the incident occurred and what action is being taken in response to the incident. Use the back of the sheet if more space is needed.)

Witness Information

Name and Address	Daytime Phone	Email Address	DOB

Name and Address	Daytime Phone	Email Address	DOB

Claimant Information

Name of Injured Party	DOB	checkboxes
Address
Home Phone #	Business Phone #	Email Address
Description of Injury (nature and extent of; please be specific):

Transported by Ambulance	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)
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.)

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

October 7, 2020 7:45 am PDT

Incident Report Form Uploaded by Anna Davis - adavis@gsanetwork.org IP 2601:c7:4200:7080:fdc9:fe0b:9f2c:31e4