United States Ski and Snowboard Incident Input

U.S. Ski & Snowboard Incident Input

FIRST REPORT OF INCIDENT
* Denotes a Required Field

Report should be completed/submitted by Event Organizer, Official, or Coach (with no relationship to Claimant)

Event Organizers: Please complete all required fields to the best of your ability. A claim cannot be started without this information.
Please note that completing this form is not a guarantee of coverage.

Coverage Underwritten By:
Mutual of Omaha Insurance Company
Mutual of Omaha Plaza
Omaha, NE 68175

Basic Information

Loss Date (MM/DD/YYYY) *
For example, 10/22/2019

Time of Incident

Incident Description *

Injured Person Information

First Name *

Last Name *

Gender *

Birth Date (MM/DD/YYYY)
For example, 10/22/2019

Address

Address - 2 (if needed)

City

State

Zip

Phone

Marital

Event Details

Member Number

Level

Soc. Sec. No. (XXXXXXXXX - Please do not use dashes)

Event Name

Race Code

When Occurred*

Activity

Discipline

Injured Person's Club Name

If you have other Medical insurance please enter the company names and policy numbers. If you do not have other insurance, please type No Other Insurance.

Incident Location

Location Name *

Address

City

State *

Zip

Injury Information

Primary Injury Type

Primary Body Part Injured

Side

Transportation

Mechanism of Injury

Incident Location

Injured Person

Witness Information

Witness Name

Phone

Witness Statement

Employer and Address Information

Employer Name

Address

Address - 2 (if needed)

City

State

Zip

Guardian/Parent (If Injured Person is a Minor)

Parent/Guardian Name

Address

Address - 2 (if needed)

City

State

Zip

Information Regarding the Individual Completing This Form

Report should be completed/submitted by Event Organizer, Official, or Coach (with no relationship to Claimant)

Name*

Phone*

Title*

Date of Report (MM/DD/YYYY)*
For example, 10/22/2019