Claim / Accident Form

General Information

Chapter Name *

School *

Incident Details

Date *

Month

Day

Year

Time *

Hour

Minute

Location *

Persons Involved

List the individual(s) involved in the incident *

What is their relationship to the Fraternity? *

Any citations or arrests? *

Yes

Did the incident result in injury(s)? *

Yes

Nature and extent of injury

Did the injury require any medical attention? *

Yes

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

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

If Yes, describe the nature and extent of the damage:

Has the school been notified? *

Yes

If Yes: Name and Title

Was a Police Report filed concerning this incident? *

Yes

If yes, please attach a copy to this report.

Police Report Attachment

Has there been any media coverage of this incident? *

Yes

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

Day

Year

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