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Get Nonprofits Insurance Alliance Group Incident Report Form 2014-2021

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. Business Fax State Zip E-mail Address Incident Information Date of Incident Day of Week circle one Mon Tue Wed Thurs Fri Time of Incident Sat Sun Did the incident occur on organization s premises AM / PM Yes No 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 DOB Including ALLIANCE OF NONPROFITS FOR INSURANCE ANI www. insurancefornonprofits. org Claimant Information 1. Name of Injured Party Employee Client Volunteer Visitor Other Address Street Home Phone 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. use the back of the form or attach an additional sheet of paper if needed PRINT NAME OF INDIVIDUAL COMPLETING THE FORM Rev 10/2014 SIGNATURE DATE Pg 2 of 2. 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. 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 Business Phone City Ext. Business Fax State Zip E-mail Address Incident Information Date of Incident Day of Week circle one Mon Tue Wed Thurs Fri Time of Incident Sat Sun Did the incident occur on organization s premises AM / PM Yes No 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 DOB Including ALLIANCE OF NONPROFITS FOR INSURANCE ANI www. insurancefornonprofits. org Claimant Information 1. Name of Injured Party Employee Client Volunteer Visitor Other Address Street Home Phone 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* use the back of the form or attach an additional sheet of paper if needed PRINT NAME OF INDIVIDUAL COMPLETING THE FORM Rev 10/2014 SIGNATURE DATE Pg 2 of 2. .

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