Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In the first section, input the name of the insured person in the designated field, followed by the name of the person who was injured. Make sure the details are accurate and clearly written.
3. Provide the certificate number associated with the insured individual. This identifier is crucial for the processing of your claim.
4. Enter the date of the accident in the specified space. Ensure that the date is complete and correct.
5. Describe the accident in detail. Include the date, time, and location of the incident, along with a narrative of how it occurred. Be sure to provide the address where the injury took place and include the property owner's name as well as their insurance company’s information, including contact details and policy number.
6. Indicate whether the accident was related to employment. If applicable, provide the complete name and address of the employer.
7. If a police report was filed, mention this and attach a copy of the report to your submission.
8. For accidents involving a motor vehicle, furnish the name, address, and contact number of the auto insurance carrier managing the claim.
9. State if the accident pertains to an organized athletic activity. If so, confirm whether an accident report was filed with the sports coordinator, and include copies of any related documents.
10. If you have engaged legal representation regarding the accident, please provide the full name, address, and contact number of your attorney.
11. Finally, sign and date the form in the designated fields to validate your submission.
12. After completing the questionnaire, save the changes, and then download, print, or share the form as needed for your records.

Complete your documents online today to ensure accurate processing of your insurance claim.