GSA Network

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:

Signature arrow
Signature Certificate
Document name: Incident Report Form
lock iconUnique Document ID: e8d912a38d9b97542e146741fd9dc078efc3e83e
Timestamp Audit
October 7, 2020 7:45 am PDTIncident Report Form Uploaded by Anna Davis - adavis@gsanetwork.org IP 2601:c7:4200:7080:fdc9:fe0b:9f2c:31e4