1. Please provide the information requested below about yourself.

Relationship to Participant:

2. Please provide the information requested below if other than the Participant.

3. Please provide the following information as to why medical treatment was received.

Type of Injury:

Was a police report filed?

*If yes, please submit a copy of the police report

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4. Please briefly describe the circumstances surrounding the injury and medical treatment received.

5. Have you retained an attorney to assist you in recovering part or all of the losses you sustained as a result of the Injury?

*If yes, please provide the following information.

I hereby certify that to the best of my knowledge and under the penalty of law, the information provided herein is true, correct and complete.  I understand that providing false information may lead to refusal of this claim.  

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