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Injury Form - Metro Softball Umpires Association

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Injury Form - Metro Softball Umpires Association Powered By Docstoc
					                                                                                                      Claim#

                                                                                 CLAIM/ INCIDENT REPORT

              Note: Use this form (1) to report any claim which causes bodily injury or property damage or (2) to report any
                                incident which has the potential to cause bodily injury or property damage.


  Department                                                      Phone                       Reported by:

    Location:                                             Date:                     Time:              Date Reported:




Personal Injury              Claim            Incident                             Property Damage             Claim            Incident

Name of Indured or Claimant:                                                       Unit or Vehicle#

Address:                                                                           Year, Make and Model

                                                                                   Property Damaged:
City, State, Zip:                                        Phone:

Occupation:                                              Age:
                                                                                   Nature of Damage:
Part of Body Injured

Nature of Injury




Insurance Company/ Agent:                                                          Estimated Cost to Repair/Replace:

  Wintesses         1.)                                                                                        Phone:
  Names and
  Addresses         2.)                                                                                        Phone:




Police Report Number:

Describe Clearly how the claim/incident occurred (attach any supporting data):




Submitted by:                                 Date:                       Reviewed by:                                  Date:


                Please forward the original signed form to Finance Administration, Attn: Mark Carufel.
                                              *A supervisor must sign the completed form

				
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