Incident Notification Form


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For completion by Insured Member/Club or Association Official only

Incident Notification Form Please complete and return this document to:

[email protected]

Alternatively post it to us:

Claims Department, Perkins Slade Ltd 3 Broadway, Broad Street Birmingham B15 1BQ 0121 698 8140

For enquiries or help completing this form contact:

Please retain a copy for your files

INSURED MEMBER Name: Address:

Tel: Email: Name of Association in full:

Membership No:

Membership/Licence valid from: To: Please advise if you are a member of any other Association, if so quote full name:

ACCIDENT/INCIDENT Place: Date: Circumstances:

Was the accident reported under RIDDOR? Was medical assistance provided or ambulance called?

Time:

Yes

No

Please attach a copy of your form

DETAILS OF INJURED PERSON Name: Address:

Tel: Email: Occupation: Details of injuries:

D.O.B:

Age:

Perkins Slade is authorised and regulated by the Financial Services Authority. Perkins Slade Limited is registered at Companies House in England and Wales under Company number 969374. Registered Office: 3 Broadway, Broad Street, Birmingham, UK, B15 1BQ. All information provided on this form is treated by us as confidential and except to the extent required by law, we shall only use such information for the purposes of processing your claim. Information you provide may be forwarded to your insurer for these purposes. INF_CR_10/12

For completion by Insured Member/Club or Association Official only DETAILS OF THIRD PARTY PROPERTY DAMAGE Name of Property Owner: Address:

Tel: Email: Full details of damage:

Has blame been apportioned? (please circle) If Yes state by whom and in what format:

Yes

No

In your view, who is responsible for the incident? Please outline any implied or actual threat of legal action arising out of the incident:

WITNESS (IF AVAILABLE) Name: Address:

Tel: Email: Additional information/comment/opinion (in confidence):

Signed:

Print name:

Date:

TO BE COMPLETED BY CLUB OR ASSOCIATION OFFICIAL Name: Address:

Tel: Position in Club: Email: Is claimant a current club or associate member? (please circle) Yes Did the accident take place whilst participating in an insured activity? Yes Do you confirm all the above is correct? Yes If you answered “No” to any of the above please explain:

Signed:

Print name:

No No No

Date:

Perkins Slade is authorised and regulated by the Financial Services Authority. Perkins Slade Limited is registered at Companies House in England and Wales under Company number 969374. Registered Office: 3 Broadway, Broad Street, Birmingham, UK, B15 1BQ. All information provided on this form is treated by us as confidential and except to the extent required by law, we shall only use such information for the purposes of processing your claim. Information you provide may be forwarded to your insurer for these purposes. INF_CR_10/12