CLAIM SHEET FOR INTERCOLLEGIATE CLAIMS
IMPORTANT: THIS INFORMATION MUST BE GIVEN OR CLAIM WILL BE RETURNED.
COLLEGE OFFICIAL TO COMPLETE
   
Name of Institution:  
Student's Full Name:  
Student's Home Address:  
City:  
State:  
Zip Code:  
Student's College Address:  
City:  
State:  
Zip Code:  
Student ID Number:  
Student's Date of Birth:  
Student's Gender   Male        Female
Grade:  
Marital Staus:  
ACCIDENT INFORMATION:
Date of Accident:      
Time of Accident    
Detailed Description of the Accident. How did it occur?:  
Where did it occur?:  
Part of Body Injured:  


Right        Left

 
Activity:   Sport:
Intercollegiate
Intramural
Other:
Name of College Authority supervising activity:  
Was the Supervisor a witness to the accident?:   Yes        No
If not, when was the accident first reported to a college authority?: