ACCIDENT REPORT FORM
808 Pacific Street, Vancouver, BC V6Z 1C2
Tel: 1.604.714.2233 / Fax: 1.604.714.2232 /
ATHLETE INFORMATION / Name:
Address: / Date: / DD: / MM: / YY:
Telephone:
Email: / Sex: / Male / Female
Club/Team:
GENERAL ACCIDENT INFORMATION
DISCIPLINE (SELECT ONE)
MOGULS / AERIALS / HALFPIPE / SLOPESTYLE / BIG AIR / OTHER
Ski Hill/Training Area Name/Location:
Time of Injury:
(Be as specific as possible)
Coach On Location:
DESCRIPTION OF ACCIDENT:
INJURY INFORMATION (CHOOSE ALL OPTIONS THAT APPLY IN EACH MENU)
BODY PART INJURED
Head/Face / Neck / Shoulder/Clavicle / Upper Arm / Elbow / Forearm / Wrist
Hand/Fingers / Chest/Ribs / Upper Back / Abdomen / Lower Back / Buttocks
Hip/Groin / Thigh / Knee / Lower Leg/Achilles / Ankle / Foot/Toes
Information Not Available / Other:
SITE OR LOCATION OF INJURY
Right / Left / Middle / Other:
INJURY TYPE
Fracture/Bone Stress / Joint/Ligament / Muscle/Tendon / Contusion / Laceration
Nervous System / Concussion / Suspected Concussion / Information Not Available
Other:
EXPECTED ABSENCE FROM TRAINING/COMPETITION
No Absence / 1 to 3 days / 4 to 7 days
8 to 28 days / More than 28 days / Information Not Available
INJURY CIRCUMSTANCES(CHOOSE ALL OPTIONS THAT APPLY IN EACH MENU)
TYPE OF ACTIVITY
On Snow Training / Dry Land Training / Water Ramp / Trampoline / Competition
TYPE OF SNOW (ON SNOW ONLY)
Natural Snow / Artificial/Man-made snow (from snow gun)
COURSE CONDITIONS (ON SNOW ONLY)
Icy / Soft / Compact / Fresh Powder / Exposed Ground
WEATHER CONDITIONS (choose all that apply)
Sunny/Clear / Cloudy/Overcast / Raining / Snowing
Foggy / Flat Light / Artificial Light
WIND CONDITIONS (choose all that apply)
No Wind / Light Wind / Moderate Wind / Heavy Wind
TREATMENT INFORMATION
Name of attending physician/para-medical personnel:
On-Site Treatment:
IF ATHLETE WAS HOSPITALIZED: / Name of Hospital:
Name of Doctor: / Hospital Address:
Treatment:
INSURANCE INFORMATION
DID THIS MEMBER PURCHASE FREESTYLE CANADA ACCIDENT INSURANCE WITH THEIR LICENCE?
Yes, 2A (In-Country) / Yes, 2B (In-And-Out-Of-Country) / No / Unknown
Did this member incur any medical fees associated with this injury on the day of the accident? (e.g. ambulance fees, hospital fees, other medical service expenses, etc.)
Yes / No / Unknown at this time
Does this member expect to incur further medical expenses as a result of this injury? (e.g. physiotherapy, surgery, other medical procedures, etc.)
Yes / No / Unknown at this time
THIS FORM COMPLETED BY
/ Date: / D`D: / MM: / YY:Name: / Signature/Electronic Signature:
Phone:
ACCIDENT REPORT FORM
2016-2017
THIS SECTION ONLY FOR MEMBERS WHO PURCHASED 2A OR 2B ACCIDENT INSURANCE THROUGH FREESTYLE CANADA:1. ACCIDENTS OUTSIDE OF CANADA (2B): A)Contact Specialty Assist ASAP after the accident to assess medical options; their contact info is below. B) Complete this form within 24 hours of accident. C) Send to FREESTYLE CANADA ASAP. (Info at top of page).
2. ACCIDENTS WITHIN CANADA (2A/2B): A)Complete this form within 30 days of accident. B) Send this completed form to FREESTYLE CANADA (contact info at top of page).
CONTACT AIG ASSIST 24-HR Medical Assistance Service:
For any and all medical emergency requiring treatment, hospitalization or emergency repatriation, contact:
Canada & USA: +1-877-204-2017 Worldwide:+0-715-295-9967 (collect call)
Local Claims Office: +1-877-317-8060 (8:45 am-4:45 pm EST)
POLICY #: SRG 9144067
PLEASE COMPLETE THE CLAIM FORMS IF YOU ARE INTENDING TO MAKE A CLAIM
ACCIDENT REPORT FORM
2016-2017