ACCIDENT REPORT

**Note: This form is to be filed with the Recreation Office within 48 hours of the accident. If this form is not submitted within the specified time, the Insurance Company will not be responsible for payment of any claim.

NAME: TELEPHONE:

HOME ADDRESS:

DATE OF ACCIDENT: TIME OF ACCIDENT:

PLACE OF ACCIDENT:

Brief description of the Activity and Injury____________________________________________

WITNESS: SUPERVISOR:

TREATMENT:_________________________________________________________________

Parents Names:_______________________________________________________________

Parents Notified: ( ) Yes ( ) No

First Aid Squad called: ( ) Yes ( ) No

Name of First Aid Squad Supervisor:______________________________________________

Signature of Site Director or Person in charge:_______________________________________

Township Insurance will provide limited secondary coverage after first submitting to your own Insurance Company.

This form must be in the Recreation Office within 48 hours of the accident, or the Insurance Company will not make payment.