Claim/Incident Report Form

Please fill out Claim/Incident Report form where applicable.

To prevent delays, please provide documentation from the Claimant's health-care provider, if available, to support this claim. If you have additional bills or medical documentation that relates to this diagnosis other than the documentation defined, please submit them for review of additional benefits. Please be advised that failure to complete all sections may result in delay in processing this claim. Be advised it may become necessary to request additional materials and/or interview witnesses in order to make a coverage determination. Disclaimer: Some of the services listed may not be covered by the policy.

Coverage	Carrier	Policy number	Each Occurrence	Aggregate	Deductible
Abuse/Molestation	Texas Insurance Company	BESGLPTNV011301_170012_02	$1,000,000.00	$1,000,000.00	$0.00
Excess Liability	Texas Insurance Company	BESGLXTNV011301_170012_02	$3,000,000.00	$3,000,000.00	$0.00
General Liability	Texas Insurance Company	BESGLPTNV011301_170012_02	$1,000,000.00	$3,000,000.00	$1,000.00
Accident Medical	United States Fire Insurance Company	US2166937	$25,000.00	$1,000,000.00	$1,000.00

Named Insured / Policyholder / Organization Name

Event, Activity or Sport

Country

Street Address

City

State

Zip Code

Did Accident Occur (Check Yes or No for Each of the Following)

During a participating organization sponsored & supervised, or sanctioned activity?

On activity premises?

While traveling directly and uninterruptedly to or from the activity?

During a participating organization practice?

Name and Title of Representative

Date

Participating Organization Representative E-mail

Participating Organization Representative Telephone Number

(This* denotes a required field). If claimant is a minor, provide information for parent/Guardian

*Last Name

Suffix

*First Name

Middle Name

Date Of Birth

Gender

*Telephone Number

*E-mail Address

*Guardian or Accompanying Adult Name

*Guardian or Accompanying Adult Telephone

*Home Address

*City

*State

*Zip Code

*Please describe Incident/Injury below:

Accident Location

Was Another Guest / Participant Injured?

Yes

No

Was EMS called?

Yes

No

Was law enformcement called?

Yes

No

Was a weapon involved?

Yes

No

Day of Week of Incident

*Date of Incident

Time of Incident include AM or PM

Incident / Injury Business Hours Event? After hours Options?

Was Blood or Bodily Fluids Involved with Incident?

Yes

No

Was BBP Cleaning Kit Available if Blood or Bodily Fluids were involved?

Yes

No

Type of Incident?

Type of Injury

Body Part Injured

Injury Attraction or General Area

Incident - Injury Location

Attraction

Were Rules Sign Visible at Attraction of Incident - Injury?

Yes

No

Were General Court Rules Signs Visible at Waiver Station?

Yes

No

Guest Requested Contact for Claims?

Yes

No

Guest Requested Financial Assistance with Medical Bill?

Yes

No

Injury-Incident is Mentioned on Social Media or Reporter Inquiry?

Yes

No

Waiver for guest?

Yes

No

Waiver Kiosks Operational?

Yes

No

Electronic or Paper Waiver?

Paper

Electronic

Video Footage Available of Incident-Injury?

Yes

No

Accident location Operational?

Yes

No

Has the Insured Made Contact with The Guest Post Incident?

Yes

No

Has the Incident-Injury Class Been Updated, If Warranted?

Yes

No

Has the Waiver(s) Been Saved?

Yes

No

Has the Video(s) Been Saved?

Yes

No

Report Completed by (Full Name):

Injury report complete by title:

Was injury a result of participating in an organized sporting activity?

Yes

No

Type of Event AND Sporting Organization

Was this a motor vehicle accident in which the patient was the driver? (If yes, please submit a copy of the Police Report.)

Yes

No

Was death a result of this injury? (If yes, please submit the certified death certificate and the Life Beneficiary's Statement.)

Yes

No

Was the patient confined to the hospital as a result of this injury? (If yes, please submit the itemized hospital bills.)

Yes

No

Hospital Name

City

State

Was the patient transported by an ambulance as a result of this injury? (If yes, please submit the ambulance bill.)

Yes

No

Was an aid in locomotion (mobility) prescribed as a result of this injury? (i.e., crutches, wheelchairs, leg braces, back braces, walkers, cervical collars, etc.)

Yes

No

If any of the following were the result of your injury, please provide medical records, physician's office notes, or any bills received for these conditions that describe the diagnosis or type of treatment received:

Coma

Burn

Laceration

Dislocation

Injury to the Eye

Paralysis

Concussion (major diagnostic exam reports are acceptable)

Fractures (x-ray reports or major diagnostic exam reports are acceptable)

Was surgery performed as a result of this injury? (If yes, please submit a copy of the operative report or detailed billing from the surgeon's office.)

Yes

No

Was a major diagnostic exam (i.e., CT Scan, MRI, MRA, EEG) performed as a result of this condition? (If yes, please submit a copy of the exam report and billing information.)

Yes

No

Details Of Therapy Or Treatment

Date of Therapy or Treatment

Provider Name

Address

Phone Number

Type of Treatment

Therapy

Follow-up

Some policies provide benefits for therapy including physical, speech, and occupational therapy. Not all types are available on all policies. Please submit information indicating date of treatment, treatment type, and who provided it to determine benefit.

Transportation/Lodging Information: Please complete if you are filing a claim for transportation or lodging and please submit the hotel receipts and mileage information. For additional information, please refer to your policy language.

Date of Trip

Trip Departure Location

Trip Destination

Round Trip Mileage

OTHER INSURANCE STATEMENT

Do you/spouse/parent have medical/health care or are you enrolled as an individual, employee or dependent member of a Health Maintenance Organization (HMO) or similar prepaid health care plan, or any other type of accident/health/sickness plan coverage through an employer, a parent's employer or other?

Yes

No

If Yes, name of insurance company

Policy Number

Mother's (Guardian's) primary employer name

Mother's (Guardian's) primary employer address

Mother's (Guardian's) primary employer telephone

Father's (Guardian's) primary employer name

Father's (Guardian's) primary employer address

Father's (Guardian's) primary employer telephone

Are you eligible to receive benefits under any governmental plan or program, including Medicaid?

Yes

No

If yes, please explain

I authorize medical payments to physician or supplier for services described on any attached statements enclosed. If not signed, please provide proof of payment.

*Signature

*Date

I authorize any physician, medical professional, hospital, covered entity as defined under HIPAA, insurer or other organization or person having any records, dates or information concerning the claimant to disclose when requested to do so, all information with respect to any injury, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records or all such records in their entirety to A-G ADMINISTRATORS LLC, on behalf of United States Fire Insurance Company or its designated administrator. This authorization shall remain valid for a period of two years from the date signed. A photo static copy of this authorization shall be considered as effective and valid as the original. A copy of the authorization is available upon request of the company.

I agree that should it be determined, at a later date, there is other insurance (or similar), to reimburse A-G ADMINISTRATORS LLC, on behalf of United States Fire Insurance Company to the extent of any amount collectible. I understand that any person who knowingly and with the intent to defraud or deceive any insurance company; files a claim containing any material by false, incomplete or misleading information may be subject to prosecution for insurance fraud.

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. By entering my name below I certify that the foregoing information is true and correct.

*Signature

*Date

FRAUD WARNING STATEMENT

• FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

• ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

• ALASKA: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

• CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

• COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

• FLORIDA WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

• IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

• KANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of insurance fraud as determined by a court of law and may be subject to fines and confinement in prison.

• KENTUCKY:
Application: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Claim Form: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

• MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

• NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

• NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

• NEW MEXICO and PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

• OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

• OKLAHOMA: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

• TENNESSEE It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

• TEXAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

• VIRGINIA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

• NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Claim/Incident Report Form

Record a claim for: USA Ball Hockey Foundation, Inc. [A-SP-SU-24-09-19-320924]

Please fill out Claim/Incident Report form where applicable.

Coverage Information

NAMED INSURED/ POLICYHOLDER/ ORGANIZATION NAME STATEMENT

CLAIMANT INFORMATION