United States Ski and 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

Loss Date (MM/DD/YYYY) *

Expected format: MM/DD/YYYY

Time of Incident

Incident Description *

First Name *

Last Name *

Gender *

Birth Date (MM/DD/YYYY)

Expected format: MM/DD/YYYY

Address

Address - 2 (if needed)

City

State

Zip

Phone

Marital

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.

Location Name *

Address

City

State *

Zip

Primary Injury Type

Primary Body Part Injured

Side

Transportation

Mechanism of Injury

Incident Location

Injured Person

Witness Name

Phone

Witness Statement

Employer Name

Address

Address - 2 (if needed)

City

State

Zip

Parent/Guardian Name

Address

Address - 2 (if needed)

City

State

Zip

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)*

Expected format: MM/DD/YYYY

U.S. Ski & Snowboard Incident Input