Athletic Program Insurance Claim
Claimant Information
Name: [Your Name]
Address: 1234 Elm Street, Springfield, IL 62701
Phone Number: (555) 123-4567
Email: [Your Email]
Date of Birth: January 15, 2025
Policy Number: AP123456789
Incident Information
Date of Incident: July 25, 2051
Time of Incident: 3:00 PM
Location of Incident: Springfield High School Football Field
Type of Athletic Program: High School Football Training Camp
Description of Incident
On July 25, 2051, I sustained an injury at the Springfield High School Football Field when another player collided with me during a routine training drill, causing me to fall awkwardly on my left leg and experience severe pain, preventing me from continuing the session.
Injury Details
Type of Injury: Fractured Left Tibia
Medical Treatment Received: On-site first aid was administered immediately after the incident. I was then transported to Springfield General Hospital where I underwent X-rays and was diagnosed with a fractured left tibia. I was admitted to the hospital for further treatment and observation.
Medical Provider Information
Hospital/Clinic Name: Springfield General Hospital
Doctor’s Name: Dr. Emily Smith
Doctor’s Contact Number: (555) 987-6543
Additional Information
Was a Police Report Filed? No
Was an Incident Report Filed with the Athletic Program? Yes
If Yes, Provide Report Number: SPR-FB-2051-0725
Insurance Information
Insurance Company Name: Athletic Program Insurance Co.
Policy Number: AP123456789
Claim Number (if already assigned): CLM2051-0725
Signature
By signing below, I certify that the above information is true and accurate to the best of my knowledge.
[Your Name]
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