Sigma Chi Risk Management Foundation
to educate chapters on risk management and to assist chapters in times of loss.
Home
About Us
Education & Resources
Model Risk Management Plan Template
Alcohol
Hazing
Crisis Management
House & Fire Safety
Party & Event Planning
Case Studies
Video Resources
Policies and Guidelines
Featured
Robert E. Joseph RMF Award
Robert E. Joseph Award Winners
2017-2018 E-Payment Savings
Experiential Ratings
Insurance Services
Property and Loss Control
Certificates of Insurance
Understanding Certificates of Insurance
Request a Standard Certificate of Insurance
Request an Additional Insured Certificates
Request an Evidence of Insurance (EOI) Certificate
Report a Claim or Accident
Claim / Accident Form
Report a property damage claim
Basic Insurance Information
Request ACH Payment Information
RMF Membership Application
General Liability Only
Property Only
Contents Coverage
Colonies
FAQ
Contact
Board of Directors and Staff
Presentation Requests
Links / Partners
Careers / Job Openings
Search form
Search
You are here
Home
»
Insurance Services
»
Report a Claim or Accident
Claim / Accident Form
The Chapter President should complete this form within 24 hours of the incident.
General Information
Chapter Name
*
School
*
Incident Details
Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2016
2017
2018
2019
2020
Time
*
Hour
hour
1
2
3
4
5
6
7
8
9
10
11
12
:
Minute
minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
am
pm
Was it a Chapter House Property?
*
Yes
No
Was the Property
*
Owned
Rented
Was alcohol involved?
*
Yes
No
Location
*
Persons Involved
List the individual(s) involved in the incident
*
What is their relationship to the Fraternity?
*
Any citations or arrests?
*
Yes
No
Did the incident result in injury(s)?
*
Yes
No
Nature and extent of injury
Did the injury require any medical attention?
*
Yes
No
If so, describe in detail below
Was the person(s) injured involved in a task/job/other
*
Employee Information
Was the person an Employee?
*
Yes
No
Length of time employed?
In Years and Months
If yes, who is the supervisor?
Phone
Incident Report
Provide a detailed factual account of what happened, including relevant information about the nature of the activities
*
Did this incident result in any property damage?
*
Yes
No
If Yes, describe the nature and extent of the damage:
Has the school been notified?
*
Yes
No
If Yes: Name and Title
Was a Police Report filed concerning this incident?
*
Yes
No
If yes, please attach a copy to this report.
Police Report Attachment
Has there been any media coverage of this incident?
*
Yes
No
If Yes, Please Describe
Witnesses to this Incident
Chapter President Name
*
Chapter President Cell Phone Number
*
Chapter President Email Address
*
Witness 1 Name
*
Witness 1 Cell Phone Number
*
Witness 1 Email Address
*
Witness 2 Name
Witness 2 Cell Phone Number
Witness 2 Email Address
Witness 3 Name
Witness 3 Cell Phone Number
Witness 3 Email Address
Form Completed By
Name
*
Title
*
Email Address
*
Phone
*
Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2016
2017
2018
2019
2020
Home page